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Medical Orders

Module 1 and 2

What is an admission sheet contain? contains personal and financial information about the client
What is a physical and history form? it is used by admitting doctor or delegate (intern) for routine exams
What is a nursing history form? on admission, the nurses will record assessment data (vital signs)
What are progress notes? all care given to the client is recorded by all team members
What is a graphics sheet? records all vital signs in graphic form
What is a laboratory profile sheet? contains reports of laboratory studies that have been completed
What is a consent form? a general consent form for treatment within the hospital that is signed in admitting
What is a doctor's order sheet? form on which doctor writes orders which outline the plan for the client
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
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
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
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.
How must an order be given to HUC to process it? (1) must be written (2) must be dated (3) must be signed
What info must HUC know to correctly implement medical orders? Must know when the order is to be carried out and for how long
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
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
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
What is a patient care summary? (1) electronic Kardex (2) can be printed on demand (3) most up to date info on client
Created by: KariTansowny