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Clinical Secretary

Clinical secretary review

A device used to check hearing. tuning fork
A device used to examine the ears. otoscope
A device used to examine the eyes. opthalmoscope
A device used to listen to the heart. stethoscope
A device used to take blood pressure. sphygmomanometer
A plastic bracelet used on every admission. ID band
A specialist dictates his findings. consultation report
A unique number assigned to each client. hospital number
All equipment and supplies, other than those that must be sterilized, are obtained here. stores/materials management
Any medication given to a client must be recorded and signed for. MAR-medication administration records
Billing provincial territorial plans. business office
Care for a client with an illness expected to run a short course. acute care
Care for a person with a terminal illness. palliative care unit
Care for someone with a chronic illness. chronic care
Chart begins with this. admission (face) sheet
Confidential room for doctors to dictate. dictation room
Covering two units. cross-coverage
Ensures that equipment is safe and operational. maintenance-environmental engineer
Essential client information passed on to the next shift of nurses. shift report
Gathers a basic health history. admission interview/assessment form
Interconnecting tunnels that connect all units. pneumatic tube
Internal communication systems pa system/paging/intercom
Kept mostly by nurses. nurses' notes
Medical crisis. critically ill
Mini-elevator for small objects. dumbwaiter
Must be dated and signed each time a new order is given. doctors' orders sheet
Oversees infection control policies and procedures within the facility. risk management/infection control
Physician's assessment of the client's response to treatment. progress notes
Plastic card imprinted with essential client information. hospital card
Preprinted with essential client information. ID labels
Provides a method of tracking initials. signature sheet
Provides all client meals. nutritional services
Responsible for all charts generated within the hospital. health information services/medical records
Responsible for all medication used in the hospital. pharmacy
Responsible for communication systems within the hospital. information services
Responsible for community liaison. public relations
Responsible for employees' work-related medical needs. employee health services
Responsible for recruiting and interviewing new employees. human resources (HR)
Responsible for sterilizing and distributing sterile equipment. sterile processing dept. (SPD)/central supply material management
Responsible for supplying client-care units with clean laundry. laundry
Responsible for taking inventory. purchasing department
Responsible for the cleanliness of the facility. housekeeping/environmental services
Result that deviates from normal and causes concern. critical value
Room for friends and relatives to visit. waiting room/reception
Room used for teaching outpatients. client teaching room
Stores frequently used supplies. clean utility room
Stores medications and IV drug solutions. medication room
Stores pails, mops, other cleaning supplies. housekeeping supply room
Stores used equipment and supplies. dirty utility room
Stores wheelchairs, IV poles, gurneys, etc. storage room
Team conferences, meetings, client interviews conference room
The boundaries of a person's responsibilities. scope of practice
The head office. nurse's station
"The hub of the wheel" clinical secretary (CS)/ward clerk
Unpaid workers who visit patients. auxiliary/volunteer services
Used to perform examinations and minor procedures. treatment room
Usually the first point of contact; tracks all admissions and discharges; takes a daily census. admitting/client registration dept.
Vital signs. vital signs flow sheet
Clinical responsibilities of a Clinical Secretary Prepare/update ID bands, labels Distribute client mail Transcribe orders accurately and promptly Notify nurses of stat orders and changes in client care Maintain staffing schedules Keep charts up to date Label charts with client info and dr's name
Communication responsibilities of a Clinical Secretary Answer phone, direct calls, take msgs Notify drs/staff of death, discharge, transfers, admissions Educate clients and give info. Book appts/tests for clients Page/locate drs and other staff Direct/send reports, faxes, Xerox Keep co-workers informed
Medical client care units -nephrology -cardiology -neurology -oncology -palliative care -psychiatry (mental health) -rehabilitation -pediatrics -gynecology -maternal/child
Different healthcare facilities -general hospital -federal hospital -convalescent hospital -nursing homes -rehabilitation facilities -drug/alcohol addiction treatment -psychiatric hospitals -chronic care facilities
Forms you would find in a patients chart ( Hospital Book) -doctor's orders -multidisciplinary notes -progress notes -vital signs flow chart -signature sheet -admission (face) sheet -fluid balance sheet -lab/diagnostic test results -consultation reports
Forms from a surgical chart -consent form -pre-anesthetic questionnaire -history/physical assessment -preop checklist -anesthetic record -fluid balance sheet -surgical sheets
Created by: Barbara Ross
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