Admission
Home Health Services
What is often ordered to follow the patient to their home to ensure continuity of care occurs upon discharge?
Usually performed when the patient has died of unknown causes, has died at the hands of another, or has not been seen within a specific period of time by a physician
What is an autopsy?
For persons not directly not involved with patient care.
What is "do not give medical record access."
Action to be taken if a client brings a walker or cane into the hospital.
What is label their belongings?
These plans are developed by members of the health care team to organize the discharge for the patient.
What are discharge plans?
Document _______________ care is provided
What is after?
1. Subjective, Objective, Assessment and Plan
2. Plan, Intervention, Evaluation
3. Introduce, Situation, Background, Assessment, Recommendation, and Repeated and Verified
What is:
1. SOAP charting
2. PIE charting
3. ISBARR charting/reporting
Admission Process
What is this process called? 1.Admission criteria must be met for patients to be admitted to the hospital 2. For routine admissions, these must be met in advance 3.Criteria include the authorization for admission, which is usually handled by the physician’s office 4.Criteria also may include laboratory tests or x-rays
Patient has a sudden condition change in a long term care facility , EMS is called
What is emergency transfer
The nurse reviews with the patient their medications, orders, wound care , and other important items prior to discharge.
What is discharge teaching ?
Document the following in the nurse’s notes: Time that life signs ceased, time death was pronounced, and name of person making the official pronouncement
What is death of a patient
patient data, including patient’s name, address, phone number, insurance company, and admitting diagnosis
What is the face sheet or admissions record?
Preadmission Process
What is this process? Authorization for admission Most third-party payers require prior authorization for hospital admission All payment programs and plans have criteria that define the services covered Most plans do not cover procedures that are regarded as purely cosmetic
Nurse telephones the department and gives report
What is communication
When discharging a client with another language as their primary language, this will facilitate effective communication.
What is an interpreter.
Next step that's taken if the admission medication record shows meds that aren't ordered in the admission orders.
What is "call the provider to verify."
Leaving a computer open with a patient's information visible is...
What is a confidentiality violation?
Writing the patient name on items is the process of what?
What is the labeling belongings process
When a patient leaves the hospital before they should leave and before it is recommended they leave
What is Against Medical Advice
ID bracelet, Fall Risk, Allergy
What is bands applied to a patient at admission?
Draw a single line through the the documentation that's wrong, write ERROR (or "recorded in error or mistaken entry" ) and the nurse's initials
What is change the documentation after an error?
QD, MS, MSO4, U, IU
What are unacceptable medical abbrevations?