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Medical Orders

Module 3

QuestionAnswer
What types of admissions into the hospital are there? (1) scheduled admissions - planned and expected arrival (2) urgent admission - family doctor requests admission due to test results or other abnormal condition (3) emergency admission - comes directly from the ER or RR
What types of transfers within the hospital are there? (1) bed to bed - wishes to be by window (2) room to room - private room becomes available, requires isolation (3) unit to unit - condition or diagnosis changes
What types of discharges are there? (1) discharge home with doctor's permission (2) discharge home without doctor's permission (3) discharge to another agency (4) discharge in event of death
How to process client admission to unit? (1) greet the client warmly at nursing station (2) check identity of client (3) notify appropriate staff of client's arrival (4) keep client informed of any delays
What are the clerical duties that need to be completed once the client has arrived? (1) prepare health record (2) place labels on record - client name, doctor name, room & bed number, allergies, same name labels (3) prepare kardex (4) obtain old records if requested (5) complete all charting duties (6) notify physician (6) place record in sequence on health record rack
How does an HUC process a transfer bed to bed or room to room? (1) notify admitting of transfer and obtain permission (2) ensure "new" bed ready (3) change health record info (4) change kardex (5) alert nurses to change (6) notify departments of change - physio, dietary
How does an HUC process a unit to unit transfer? (1) notify admitting and obtain permission (2) verify record is up to date (3) ensure "new" bed is ready (4) prepare to transfer all medication, personal items and special equipment with patient (5) remove client name from unit lists (6) notify physician & departments of move (6) destroy kardex
How does an HUC process a client transfer for an incoming patient? (1) check client ID when arriving (2) inform nursing staff of arrival (3) check health record for any orders that need to be transcribed or any other info (4) print kardex and put health record away
How does an HUC process a client discharge to home with doctor's permission? (1) check for doctor's written orders for discharge (2) notify family if requested (3) make appropriate follow up appointments (4) notify departments involves with client's care of discharge (5) check for return of valuables or medication
How does an HUC process a client discharge to home without doctor's permission? (1) hopefully someone notices and they don't just leave (2) notify nurse and doctor (3) prepare "release from responsibility" form for client to sign (4) notify departments involves with client's care of discharge (5) check for return of valuables or medication
How does an HUC process a client discharge to another facility? (1) check for doctor's written orders for discharge (2) make arrangements for transfer (3) inform clients family (4) notify departments involves with client's care of discharge (5) check for return of valuables or medication
How does an HUC process a client discharge in case of death? (1) locate client's physician (2) prepare death certificate for doctor to sign (3) notify nursing office (4) arrange for family to be notified - have phone numbers ready (5) prepare autopsy permit for doctor signature - if necessary (6) obtain shroud pack and tags (7) collect all clients belongings for return to family (8) call designated funeral home if no autopsy is to be done (9) notify departments involves with client's care of discharge (10) check for return of valuables or medication
Created by: KariTansowny