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Red Module
Clinical Secretary Reverse Defs
| Question | Answer |
|---|---|
| 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 |
| 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) |
| A device that amplifies sound, used by doctors and other health care professionals to listen to the heart and to take blood pressure | stethoscope |
| A device used to examine the ears | otoscope |
| A device used to examine the eyes | ophthalmoscope |
| A device used to take blood pressure | sphygmomanometer |
| A diagnosis subject to change after an actual diagnosis has been established | provisional diagnosis or admitting diagnosis |
| A measure taken to prevent a problem from developing | prophylactic |
| A medication ordered as a single-order stat medication with a dose that is higher than the usual or routine dose | loading dose |
| A paper chart | Pchart |
| A process whereby a peer group judges an individual's qualifications to perform certain services | credentialling |
| A process wherein clients who are books for surgery receive preoperative and postoperative teaching and fill in documents ahead of time | pre-admission |
| 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) |
| 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 |
| 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 |
| 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 |
| A technician who operates the ultrasound machine | ultrasonographer |
| A test result that so deviates from normal that it causes concern for the client's immediate well-being | critical value |
| A thorough wash with a disinfectant solution of all equipment used by a client upon discharge | terminal cleaning |
| 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 |
| unique number assigned to each client admitted to hospital | hospital number |
| Acronym means "against medical advice". This refers to a patient discharging himself from hospital without the physician's approval | AMA |
| 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) |
| An electronic chart | Echart |
| Any release from a healthcare facility by a doctor's orders | discharge |
| 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 |
| 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 |
| Care for someone with a chronic illness, that is, one that typically progresses slowly but lasts for a long time, often lifelong | chronic care |
| Centralizing certain services, particularly those that require specialized care, to one hospital region | rationalization of services |
| Essential client information passed on to the next shift of nurses | shift report |
| Commonly used proprietary name for a paper-based patient care document or health record | Kardex |
| Examination of a canal, such as the colon, with an endoscope: a thin tube with lenses to allow visualization | endoscopy |
| Experiencing life-threatening problems; in medical crisis | critically ill |
| Medical and nursing care less intensive than traditional acute-care hospital treatment | subacute, transitional, or step-down care |
| Moving from one care unit to another, or covering two units | cross-coverage |
| Nonemergency, planned surgery, booked in advance | elective surgery |
| Surgery conducted with a hospital stay of less than hours | day surgery |
| The act of moving a client from one place to another within the same healthcare facility | transfer |
| The bed and other furniture used by the client are thoroughly cleaned with a specifically selected disinfectant solution | terminal cleaning |
| The process of interpreting, recording, and generating the administrative steps required for doctor's orders to be implemented | order entry |
| The relationship among hospitals that have entered into an agreement to form a partnership sharing clinical and administrative responsibilities | collaborative partnership |
| The usually rapid infusion of additional IV fluids in addition to the base amount ordered for the client | bolus |
| 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 |
| 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 |
Created by:
DawnLangridge
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