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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 |