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Clinical Secretary Reverse Defs

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A blood clot under the dura mater, the fibrous membrane forming the outer envelope of the brain and spinal cord, usually resulting from trauma to the head   subdural hematoma  
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A computer-based client-care document containing the same information as a Kardex. This is an electronic version of a traditional Kardex   electronic health record or patient intervention screen (PI screen)  
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A device that amplifies sound, used by doctors and other health care professionals to listen to the heart and to take blood pressure   stethoscope  
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A device used to examine the ears   otoscope  
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A device used to examine the eyes   ophthalmoscope  
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A device used to take blood pressure   sphygmomanometer  
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A diagnosis subject to change after an actual diagnosis has been established   provisional diagnosis or admitting diagnosis  
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A measure taken to prevent a problem from developing   prophylactic  
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A medication ordered as a single-order stat medication with a dose that is higher than the usual or routine dose   loading dose  
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A paper chart   Pchart  
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A process whereby a peer group judges an individual's qualifications to perform certain services   credentialling  
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A process wherein clients who are books for surgery receive preoperative and postoperative teaching and fill in documents ahead of time   pre-admission  
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A small basin, usually kidney shaped, used for clients to vomit into or couch up sputum or phlegm. It is also used to hold solutions for a variety of purposes. It may be ordered sterile or just clean   emesis basin or kidney basin (k-basin)  
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A special assessment for a client who has had head trauma or surgery, including checks on neurological functioning, such as verbal response and pupil dilation   head injury routine  
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A specially prepared sterile tray containing the basic equipment to change a dressing on a wound or surgical incision. It contains a k-basin, 4x4 gauze dressings, a galley cup and usually two sets of disposable forceps   dressing tray  
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A specially prepared tray similar to the dressing tray, but containing suture removal scissors or clip removers. Some facilities use a dressing tray, and nurses add a disposable suture removal blade or prepackaged clip removers   suture removal tray  
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A technician who operates the ultrasound machine   ultrasonographer  
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A test result that so deviates from normal that it causes concern for the client's immediate well-being   critical value  
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A thorough wash with a disinfectant solution of all equipment used by a client upon discharge   terminal cleaning  
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A type of endoscope that allows surgeons to visualize internal structures. Using this tool, surgery can be done through incisions often 5cm in length or smaller   laparoscope  
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unique number assigned to each client admitted to hospital   hospital number  
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Acronym means "against medical advice". This refers to a patient discharging himself from hospital without the physician's approval   AMA  
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An administrative health profession working in a hospital; an individual who assumes responsibilities for the secretarial, clerical, communication, and other designated needs of a hospital unit   clinical secretary (CS) or ward clerk (WC)  
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An electronic chart   Echart  
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Any release from a healthcare facility by a doctor's orders   discharge  
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Care for a client who is acutely ill, that is, very ill but with an illness expected to run a short course. Acute care is provided for clients with a variety of health problems   acute care  
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Care for a person with a terminal illness who is in hospital to die, to have the condition stabilized or for pain control   palliative care  
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Care for someone with a chronic illness, that is, one that typically progresses slowly but lasts for a long time, often lifelong   chronic care  
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Centralizing certain services, particularly those that require specialized care, to one hospital region   rationalization of services  
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Essential client information passed on to the next shift of nurses   shift report  
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Commonly used proprietary name for a paper-based patient care document or health record   Kardex  
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Examination of a canal, such as the colon, with an endoscope: a thin tube with lenses to allow visualization   endoscopy  
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Experiencing life-threatening problems; in medical crisis   critically ill  
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Medical and nursing care less intensive than traditional acute-care hospital treatment   subacute, transitional, or step-down care  
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Moving from one care unit to another, or covering two units   cross-coverage  
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Nonemergency, planned surgery, booked in advance   elective surgery  
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Surgery conducted with a hospital stay of less than hours   day surgery  
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The act of moving a client from one place to another within the same healthcare facility   transfer  
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The bed and other furniture used by the client are thoroughly cleaned with a specifically selected disinfectant solution   terminal cleaning  
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The process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented   order entry  
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The relationship among hospitals that have entered into an agreement to form a partnership sharing clinical and administrative responsibilities   collaborative partnership  
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The usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client   bolus  
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To draw attention to a new entry by sticking a coloured marker in, placing a coloured sticker on the back, or using some other device to visually draw attention   flag  
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Written or oral directions given by a physician to the nursing staff and other health professionals regarding the care, medications, treatment, and laboratory and diagnostic tests a patient is to receive while in the hospital   doctor's orders  
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