Admission
Transfer
Discharge
Patient Unit
Wild Card
Miscell.
100
Routine Admission
What is a scheduled, in advance admission called?
100
Document which contains pertinent information from one nursing unit to another as a means of communication of the patient's status
What is transfer form
100
Home Health Services
What is often ordered to follow the patient to their home to ensure continuity of care occurs upon discharge?
100
Device used to summon help
What is the nurse call light?
100
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?
100

For persons not directly not involved with patient care.

What is "do not give medical record access."

200
Emergency Admission
What is a unplanned admission called?
200

Loss of belongings can occur during this time

What is transfer

200
These plans are developed by members of the health care team to organize the discharge for the patient.
What are discharge plans?
200
Device which enables the patient to go to the bathroom next to the bed.
What is the bedside commode
200
Often the most important gift we can give the bereaved is just being there People need to grieve; it is an important step in healing Offer to call priest, minister, rabbi, or spiritual advisor Allow the family and friends adequate time at the bedside to say their goodbyes
What is emotional support
200

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

300
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
300
Patient has a sudden condition change in a long term care facility , EMS is called
What is emergency transfer
300
The nurse reviews with the patient their medications, orders, wound care , and other important items prior to discharge.
What is discharge teaching ?
300
Device which enables the head of the bed to be elevated, feet to be adjusted, and height of bed adjusted.
What is the bed control
300
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
300

patient data, including patient’s name, address, phone number, insurance company, and admitting diagnosis

What is the face sheet or admissions record?

400
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
400
Nurse telephones the department and gives report
What is communication
400

When discharging a client with another language as their primary language, this will facilitate effective communication. 

What is an interpreter.

400
considered a restraint half , whole, long, short can be used for repositioning can be dangerous
What is a side rail
400

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."

400

Leaving a computer open with a patient's information visible is...

What is a confidentiality violation?

500
On admission this plan begins
When does the discharge plan begin?
500
Writing the patient name on items is the process of what?
What is the labeling belongings process
500
When a patient leaves the hospital before they should leave and before it is recommended they leave
What is Against Medical Advice
500

Action to be taken if a client brings a walker or cane into the hospital.

What is label their personal belongings?

500
Patients may not be well enough to go directly home at the time of discharge RN completes a detailed patient information sheet for the receiving facility Any records to be transferred with the patient must be ready in an envelope before the transporting vehicle arrives
What is discharge to an extended care
500

QD, MS, MSO4, U, IU

What are unacceptable medical abbrevations?