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ClinicalSec Wordlist
Clinical Secretary Word List
| Question | Answer |
|---|---|
| Acute Care | Care for a client who is acutely ill,but the illness is expected to be short in duration. |
| Addressograph | Device used to imprint client information contained on the hospital card onto the client documents. |
| Admission Sheet | Face or front sheet at the beginning of a chart that contains patient demographic information. |
| Autopsy | The examination of a body to determine the cause of death and/or identify diease processes. |
| Admitting/Client information | Is the first point of contact for a patient. They take daily census and responsible for tracking all patients that are admitted and discharged. |
| Business Office | Responsible for billing provincial or territorial plans. |
| Bolus | The usually rapid infusion of additional IV fluids or an IV,IM or S/C medication in addition to the base amount ordered for a client. |
| Bone Mineral Density | BMD, uses very small doses of radiation to check the density of bone in the spine and hip. Used to detect osteoporosis. |
| Cardiology | A physician who specialized in the heart. |
| Chronic Care | Care for someone with a chronic illness, that is, one that typically progresses slowly but lasts for a long time, often lifelong. |
| Clinical Secretary/Ward Clerk | Health office professional working in a hospital;an individual who assumes responsibilities for the secretarial,clerical,communication,and other designated needs of a hospital unit or department. |
| CCU | Coronary Care Unit or Critical Care Unit of a hospital. |
| Consultation Report | Report dictated by a specialist to whom the paitent was referred. |
| Critical Value | One that indicated a life-threatening situation and requires immediate attention. The results deviates from the normal and causes concern. |
| Critically ill | Experiencing life-threatening problems;in medical crisis. |
| Cross-coverage | Moving from one area to another, or covering two units. |
| Day Surgery | Surgery conducted with a hospital stay of less than 24 hours. |
| Dietician | Registered dieticians are university graduates. Responsible for designing a diet that meets the nutritional needs of a patient while considering any medical,lifestyle, and personal preferences. |
| Discharge | Any release from a health-care facility by doctor's order. |
| Doctor's order | Written or oral directions given by a physician to the nursing staff and other health care professional regarding the care,medications,treatment, and laboratory and diagnostic tests a client is to receive while in hospital. |
| Doctor's Order Sheet | The hospital chart form that the doctor writes the order on for processing. This form must be dated and signed each time a new order is given. |
| Dumbwaiter | Lift,mini-elevator for small objects. |
| Dictation Room | Confidential room for doctors to dictate progress notes. |
| Elective Surgery | Non emergency. Planned surgery,booked in advance. |
| Embolism | Obstruction of a blood vessel by a blood clot,and air bubble, or foreign matter. |
| Emesis Basin | A small basin,usually kidney shaped,used for clients to vomit into or cough up sputum or phlegm. |
| Endoscopy | Examination of a canal,such as the colon,with an endoscope;a thin tube with lenses to allow visualization. |
| Enema | The introduction of liquid into the rectum through the anus for cleansing the bowl and for stimulating evacuation of the bowels. |
| Employee Health Services | Responsible for work related medical needs. |
| Encrypted Digital Signature | Security for computers. |
| Flag | (of a chart) 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. |
| Fractionalized Chart | A portion of a patient's chart,seperate from the main chart. |
| Graphic Record | A form that is a visual graph of a patient's vital signs. |
| Health Information Systems | Responsible for all charts generated within the hospital. |
| Housekeeping | Responsible for cleanliness of the facility. |
| Human Resources | Responsible for recuiting,interviewing and hiring new employees. |
| Hospital Cards | A plastic card imprinted with essential patient demographic information. |
| Heparin Lock | Hep Lock, a device that provides IV access when needed,without continuous infusion. It sits in the vein and must be flushed at specific intervals with saline solution or heparin solution. |
| Hospital Number | A unique number assigned to each client admitted to the hospital. |
| Identification Band | ID band, a plastic bracelet bearing the client's name and hospital number that can be removed only by cutting. |
| IV Push | IVP, a medication given into the vein or into an ongoing IV fusion, using a syringe and needle. |
| ID Stickers | Preprinted stickers that have essential patient demographic information. |
| Information Services | Responsible for maintaining communication systems within the hospital. |
| Kardex | Commonly used proprietary name for a paper-based client care document or health record. |
| Laboratory Reports | Results of lab tests, including pathology. |
| Laparoscope | A type of endoscope that allows surgeons to visualize internal structures. |
| Lateral | Side-lying, with top hip and knee flexed. |
| Laundry | Falls under environmental services. |
| Loading Dose | Medication ordered as a single-order stat medication with a dose that is higher than the usualy or routine dose. |
| Medical Administration Record | A legal document in which all medication administered to a patient is documented. a.k.a MAR. |
| Material Management | Responsible for all equipment and supplies that are not sterilized. |
| Medical Unit | Includes patients who are on telemetry,nephrology, and pediatrics. |
| Medical Records | A department in the hospital that maintains and files patient charts. |
| New Admission | A client recently admitted to the hospital. |
| Nutritional Services | Fills orders for special diets. |
| Order Transcription | The process of interpreting,recording and generating the administrative steps required for a doctor's orders to be implemented. |
| Pneumatic Tube System | Interconnecting tunnels connecting departments. |
| Pharmacy | Responsible for all medication in the hospital. |
| PA System | Communication tool that can be heard throughout the hospital. |
| Palliative Care | Care for a person with terminal illness who is in hospital to die,to have the condition stabilized, or for pain. |
| Patient Intervention Screen | A computer-based client care document containing the same information as a Kardex. This is an electronic Kardex. |
| Ophthalmoscope | Used to examine eyes. |
| Otoscope | Used to examine ears. |
| Purchasing Department | Responsible for taking and maintaining inventory. |
| Public Relations | Community liaison responsible for hospital news letter, public events, and spokesperson with the media. |
| Provisional Diagnosis | The diagnosis is subject to change after actual diagnosis reached. |
| Pre-Admission | A process wherein clients who are booked for surgery receive preoperative and postoperative teaching and fill documents ahead of time. |
| Prophylactic | A measure taken to prevent a problem from developing. |
| Physician's progress Notes | Physician's assessment of patient's response to treatment. |
| Range of motion | ROM, join through their full range of motion. |
| Registered Nurse | RN, has a university degree, may dispense medication, gives IV medication. |
| Registered Practical Nurse | RPN, is a graduate of a college program and may give out medication in a nursing home. |
| Requisition | An order form. |
| Resource Nurse | The person who coordinates and manages a unit for a shift, sometimes referred to as the charge nurse. |
| Respiratory Therapists | RT, provide inhalation treatments, set up and monitor oxygen therapy, manage clients on respirators or using spirometers, obtain blood gases, and monitor clients' respiratory progress. |
| Risk Management | Oversees infection control policies and procedures. |
| Scope of Practice | The limits or boundaries of a person's responsiblities. |
| Shift Report | Essential client information passed on to the next shift of nurses. |
| Signature Sheet | Method for tacking the initials of each health care team member that may write in a patients's chart. |
| Sphygmomanometer | Used to take blood pressure. |
| Social Worker | Helps family cope with hospitalization and make plans after discharge. |
| Step-down Care | Medical and nursing care less intensive than traditional acute care hospital treatment. |
| Stethoscope | Used to listen to the heart. |
| Supine | Lying on the back. |
| Suture Removal Tray | A specially prepared sterile tray similar to the dressing tray, but containing suture removal scissors or clip removers. |
| Terminal Cleaning | A through wash with a disinfectant solution of all equipment used by a client upon her discharge. |
| Transfer | The act of moving a client from one place to another. |
| Tuning Fork | Used to check hearing. |
| Volunteer Services | Unpaid workers in the hospital who visit with the patients, help patients find departments, and work in the gift shop. |
| Weight Bearing | Putting body weght on the lower limbs. |
| Workload Analysis | A software component that tracks types of care provided as a basis for billing the provinical health-care plan. |
| X-ray | Visual test in which an image of a selected body part or region is created by using low doses of radiation reflected on film or fluorescent screens |
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