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Clinical Secretary

Clinical secretary reverse definitions

QuestionAnswer
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 info as a Kardex. This is an electronic version of the traditional Kardex. electronic health record/ patient intervention screen (PI screen)
A device that amplifies sound, used by doctors and other healthcare 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. othalmascope
A device used to take blood pressure. sphygmemanometer
A diagnosis subject to change after an actual diagnosis has been established. admitting (provisional) 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. credentially
A process wherein clients who are booked 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 cough 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 (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 sterile 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 an 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 5 cm in length or smaller. laparoscope
A 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 (Against Medical Advice)
An administrative health professional 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) / Ward Clerk
An electronic chart. echart
Any release from a healthcare facility by 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, traditional, step down care
Moving from one 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 24 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 nursing staff and other health professionals regarding the care medications, treatment, and laboratory and diagnostic tests a patient is to receive while in hospital. doctor's orders
Created by: Barbara Ross