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1

Written instructions by doc for care & treatment of the patient upon entry into the hospital

admission orders

2

a patient that has been admitted and assigned a bed on the nursing unit

inpatient

3

a pt. admission panned in advance, ti may be urgent or elective

scheduled admission

4

a form used by nursing staff to maintain a current pt. profile and is disposed of upon pt. leaving

kardex

5

chart forms that are in addition to the standard chart forms and are added to the patient's chart according to specific care needs

supplemental forms

6

form completed by the Physician which gives a brief summary of the patient's care and history while in the hospital

Physician Progress Notes

7

form used by nursing staff to advise the Physician of any important information regarding the pt.

notes to Physician

8

completed at time of pt admission to the unit by the Nursing Staff

Nursing Assessment/History form

9

the process of obtaining info and partially preparing admitting forms before the time of pt arrival at the HCF

Pre Admit

10

Main purpose for having a chart

1. written record of pt illness treatment care & outcome from hospitalization
2. means of communication btwn nursing staff and medical staff
3. plan for future plan
4. legal purposes

11

Guidelines for entries in pt chart

1. black ink
2. transcribing symbols in red ink
3. legible and accurate
4. printed or written
5. abbreviations from list of approved

12

Assembling Chart

Addressograph all forms and put behind corresponding divider
Name labels and other pertinent labels on chart binder
Do in timely accurate manner

13

Forms that accompany pt from admitting

Admission-Separation
Consent for Treatment
Information Collection Authorization
Pt. Release form
Discharge Summary

14

Forms in a Chart Pack

Risk Alert
Discharge Summary
Notes to Physician
Allergy Caution
Orders & Directives
Nurses Notes
24 Hour Flow Sheets
Patient Data Base
Clinical Record
Fluid Balance Record
Fall Prevention
MAR
Signature Sheet

15

Admission-separation Record

pt. full name
DOB
diagnosis
Doctor
PHN
NOK
allergies
address
CCI's
contact person
type of admission

16

Form completed by Physician and nursing staff giving the pts. D/C instructions and RX

Discharge Medications & Instructions

17

4 forms that may be on clipboard by pts. bed

V/S Record
24 Hr Flow Sheet
Neurovascular Checklist
Fluid Balance Record

18

Additional or Supplemental Chart Forms

History/Physical Update
Neurovascular Checklist
Diabetic Record
Anticoagulant Chart
Fluid Balance Record

19

Info found on a Kardex

Activity Level
Diet
Code status
Allergies
History
Lab Tests
IV's
Treatments

20

Thinning

MAR
24 Hr Flow Sheet/Nurses Notes
V/S & Clinical Records
base care records

21

Types of Discharges

Home
Home with Assistance
LAMA
Tsf to another HCF
Death

22

Maintaining Pt. Chart

-know ID of persons that have access to chart
-"A" with pts name and add forms when needed
-put chart in rack when not in use
-thin chart when needed
-file diagnostic results & reports
-review for new orders
-assist in locating

23

Forms to copy & send to HCF pt transferring to

Admission-Separation
History/Consults
Diagnostic/Lab results
Current MAR & Drug Profile

24

Reports under Laboratory

chemistry
toxicology
blood bank
blood gasses
ECG
cultures

25

CCI's

ARO Antibiotic Resistant Organism
DNA Do Not Acknowledge
AVB Aggressive Violent Behavior

26

Components of Admission Orders

-Admitting Dx
-pt. code status
-diet
-activity
-meds
-diagnostic and treatment orders
-request for old records
-misc.
-observation

27

Admitting gives NUC for new admission

-type of admission
-pt.name
-pt. Dx
-pt. Doctor
-pt.sex & age
-room & bed #

28

What does NUC receive from Admitting if pt. is elective/routine admission

-Admission-Separation Record
- "A" card
-ID armband
-Allergy armband
-Discharge Summary
-Consent for Tx
-Info Collection Auth.
-Pt. Release Form
-Preferred Accom.
-ARO screening

29

Emergency Admission

Same as an Elective/Routine plus:
-crew report
-Short Stay Emergency Assessment Record
-Nurses notes/Flow Sheet
-Lab Reports
-Physicians order form
-Emergency Record
-Old Chart

30

Activity Orders

AAT
CBR
BR with BRP
Dangle
up in hall
up in chair with assist
up as tol
up ad lib