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