Module 1 and 2
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| What is an admission sheet contain? | contains personal and financial information about the client
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| What is a physical and history form? | it is used by admitting doctor or delegate (intern) for routine exams
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| What is a nursing history form? | on admission, the nurses will record assessment data (vital signs)
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| What are progress notes? | all care given to the client is recorded by all team members
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| What is a graphics sheet? | records all vital signs in graphic form
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| What is a laboratory profile sheet? | contains reports of laboratory studies that have been completed
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| What is a consent form? | a general consent form for treatment within the hospital that is signed in admitting
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| What is a doctor's order sheet? | form on which doctor writes orders which outline the plan for the client
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| How is the Health Record organized? | (1) Personal directive (2) Doctor's orders (3) physical and history (4) nursing history, progress reports (5) clinical record, medication administration record, special chart forms (6) laboratory profiles (7) misc. forms (8) admission form
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| What is the purpose of the health record? | (1) serves as a means of communication between all team members (2) form the basis for planning client care (3) provides written record of client's illness, treatment and final outcome of hospitalization (4) a legal document which protects client, physician, hospital staff and hospital (5) provides data for research and education
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| What identification must be on a health record? | Outside: (1) client's full name (2) doctor's full name (3) room and bed number (4) Allergies (5) similar name tag (if necessary) Inside: all pieces of paper must have identification stickers
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| What practices must be used to keep health record legal? | (1) all entries must be legible and written in blue or black ink (2) no use of white-out (3) date and time must accompany all entries (4) legal document that may be used in a court of law.
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| How must an order be given to HUC to process it? | (1) must be written (2) must be dated (3) must be signed
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| What info must HUC know to correctly implement medical orders? | Must know when the order is to be carried out and for how long
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| What are the 4 types of medical orders? | (1) Standing, regular, scheduled - orders that are carried out until cancelled or changed (2) Standing prn - orders carried out as needed until cancelled or changed (3) One time only orders (4) Stat - order that is implemented immediatley
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| What is a Kardex? | (1) it provides a quick, easy access to client info and treatments (2) HUC is responsible for preparing and mainteining (3) is kept in nursing station for confidentiality
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| What are the guidelines for a Kardex? | (1) it is not a legal document (2) can be discarded at discharge (3) may use pencil and entries can be erased as they change
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| What is a patient care summary? | (1) electronic Kardex (2) can be printed on demand (3) most up to date info on client
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
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You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
KariTansowny
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