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Red Module

Reverse Definitions Clinical Secretary

subdural hematoma 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
electronic health record/patient intervention screening (PI screen) a computer-based client-care document containing the same information as a Kardex. This is an electronic version of the traditional Kardex
stethoscope a device that amplifies sound, used by doctors and other health care professionals to listen to heart and take blood pressure
otoscope a device used to examine the ears
opthalmoscope a device used to examine the eyes
sphygmomanometer a device used to take blood pressure
admitting (provisional) diagnosis a diagnosis subject to change after an actual diagnosis has been established
prophyloctic a measure taken to prevent a problem from developing
loading dose a medication ordered as a single-order stat medication with a dose that is higher than the ususal or routine dose
P chart a paper chart
credentialling a process whereby a peer group judges an individual's qualifications to perform certain services
pre-admission a process wherein clients who are booked for surgery recieve preoperative and postoperative teaching and fill in documents ahead of time
emesis basin/kidney basin/K basin a small basin usually kidney shaped , used for clients to vomit into or cough up sputum or phlegm.
head injury routine a special assessement for a client who has had head trauma or surgery, including checks on neurological functioning, such as verbal response and pupil dilation
dressing tray a specially prepared sterile tray containing the basic equipment to change a dressing on a wound or surgial incision. Contains K basin, 4x4 gauze dressings, a galley cup and usually two sets of disposable forceps
suture removal tray a specially prepared sterile tray similar to the dressing tray but containing suturer removal scissors or clip removers. Can also include disposable suture removal blade or prepackaged clip removers
ultrasongrapher a technican who operates an ultrasound machine
critical value a test result that so deviates from normal taht it causes concern for the client's immediate well being
terminal cleaning a thorough wash with a disinfectant solution of all equipment used by a client upon discharge
laproscopy a type of endoscope that allows surgeons to visualize internal structures.
hospital number a unique number assigned to each client admitted to hospital
AMA Acronym for "against medical advice" Refers to a patience discharging himself from hospital without physician approval
clinical secretary/ward clerk an administrative health professional working in a hospital; who assumes responsibilities for the secretarial, clerical, communications and other designated needs of a hospital unit
E chart electronic chart
discharge any release from a healthcare facility by doctor's orders
acute care care for a client who is acutely ill, that is very ill but an illness that is expected to run a short course. Proved for clients with a variety of health problems
palliative care care for a person with a terminal illness who is in hospital to die, or have condition stabilized or for pain control
chronic care care for a person with a chronic illness, that is , one that typically progresses slowly but lasts for along time, often life long
rationalization of services centralizing certain services particularly those that require specialized care, to one hospital region
shift report essential client information passed on to the next shift of nurses
Kardex commonly used proprietary name for a paper based patient care document or health record
endoscopy examination of a canal, such as the colon, with an endoscope: thin tube with lenses to allow visualization
subacute, transitional, step down medical and nursing care less intensive than traditional acute-care hospital treatment
cross-coverage moving from one area to another or covering two units
elective surgery nonemergency, planned surgery, booked in advance
day surgery surgery conducted with a hospital stay of less than 24 hours
transfer the act of moving a client from one place to another within the same healthcare facility
order entry process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented
collaborative partnership the relationship among hospitals that have entered into a agreement to form a partnership sharing clinical and administrative responsibilities
bolus the usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client
flag to draw attention to a new entry by sticking a coloured marker in, placing a coloured sticker on he back, or using some other device to visually draw attention
doctor's orders written or oral direction given by a physician to the nursing staff ad other health professionals regarding the care, medications, treatment and laboratory and diagnostic tests a patient is to receive while hospital.
tuning fork device for checking hearing
ID wrist band a plastic bracelet used on every admission
consultation report specialist dictates his/her findings
Medication Administration Records (MAR) where medication given to a client is recorded and signed for
Acute Care care for client with an illness expected to run a short course
Palliative Care care for a person with a terminal illness
Chronic Care care for a person with a chronic/ long term illness
admission sheet first sheet in client chart also known as "face chart"
critically ill medical crisis
signature sheet sheet in client chart that provides a method of tracking initials
Pharmacy responsible for all medications used in the hospital
hospital number a unique number assigned to each client when admitted to hospital
cross-coverage covering two medical units
shift report essential client information passed to the next shift of nurses
admission interview/assessment form gathers basic health history
Risk Management over sees infection control policies and procedures within facility
Nutritional Services overs see all a client meals
Information Services responsible for all communication/ computer systems within the hospital
Public Relations responsible for community liaison
Employee Heath Services responsible for employees work related medical needs
Sterile Processing Dept/Central Supply-Materials Management responsible or sterilizing and distributing sterile equipment
Purchasing responsible for taking inventory
Housekeeping/ Environmental Services responsible for cleanliness of the facility
Maintenance ensures all equipment is safe and operational
Doctor's order sheets sheets in client chart that must be dated and signed each time a new order is given
Physician's Progress notes assessment of client's response to treatment
Medical Records/Heath Information Services responsible for all chart generated within the hospital
Created by: amatt