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VOCABULARY
VOCABULARY
VOCABULARY
ABBREVIATIONS
ABBREVIATIONS
100
PATIENT CHART FORMS USED ONLY WHEN SPECIFIC CONDITIONS OR EVENTS DICTATE
What is SUPPLEMENTAL CHART FORMS
100
FORMS INCLUDED IN ALL INPATIENT PAPER CHARTS THAT ARE USED TO REGULARLY ENTER INFORMATION ABOUT PATIENTS.
What are STANDARD CHART FORMS?
100
A PREASSEMBLED PACKET OF STANDARD CHART FORMS TO BE USED ON ADMISSION OF A PATIENT TO A NURSING UNIT
What is an ADMISSION PACKET?
100
NO KNOW FOOD ALLERGIES
NKFA
100
NO KNOW ALLERGIES
What is NKA
200
A PATIENT'S PAPER RECORD FROM PREVIOUS ADMISSIONS, STORED IN THE HEALTH INFORMATION MANAGEMENT DEPARTMENT, THAT MAY BE RETRIEVED FOR REVIEW WHEN A PATIENT IS ADMITTED TO AN EMERGENCY ROOM, NURSING UNIT, OR OUTPATIENT DEPARTMENT; OLDER MICROFILMED RECORDS MAY BE REQUESTED BY THE PATIENT'S DOCTOR.
What is an OLD RECORD?
200
A LOCKED WORKSTATION THAT IS LOCATED ON THE WALL OUTSIDE A PATIENT'S ROOM; IT STORES THE PATIENT'S PAPER CHART OR A LAPTOP; AND WHEN UNLOCKED IT FORMS A SHELF TO WRITE ON.
What is a WALLaroo?
200
A PLASTIC BRACELET(USUALLY RED) THAT IS WORN BY A PATIENT THAT INDICATES ALLERGIES HE OR SHE MAY HAVE.
What is an ALLERGY BRACELET?
200
MEDICATION ADMINISTRATION RECORD
What is MAR?
200
IDENTIFICATION LABELS
What is ID Labels?
300
AN ACQUIRED, ABNORMAL IMMUNE RESPONSE TO A SUBSTANCE THAT DOES NOT NORMALLY CAUSE A REACTION; SUCH SUBSTANCES MAY INCLUDE MEDICATIONS, FOOD, TAPE, AND MANY OTHER ITEMS.
What is an ALLERGY?
300
A LABEL AFFIXED TO THE FRONT COVER OF A PATIENT'S PAPER CHART THAT INDICATES THE PATIENT'S ALLERGIES HER OR SHE MAY HAVE.
What is an ALLERGY LABEL?
300
A METHOD OF ALERTING STAFF WHEN TWO OR MORE PATIENTS WITH THE SAME OR SIMILARLY SPELLED LAST NAMES ARE LOCATED ON A NURSING UNIT.
What is a NAME ALERT?
300
HISTORY AND PHYSICAL
What is H&P?
300
NO KNOWN DRUG ALLERGIES
What is NKDA?
400
LABELS THAT CONTAIN INDIVIDUAL PATIENT INFORMATION FOR IDENTIFYING PATIENT RECORDS OR OTHER PERSONAL ITEMS.
What is an IDENTIFICATION LABEL?
400
PLACING EXTRA CHART FORMS IN PATIENT'S PAPER CHARTS SO THEY WILL BE AVAILABLE WHEN NEEDED.
What is STUFFING CHARTS?
400
PORTIONS OF THE PATIENT'S CURRENT PAPER CHART ARE REMOVED WHEN THE CHART BECOMES SO FULL THAT IS IS UNMANAGEABLE.
What is a SPLIT OR THIN CHART?
400
HISTORY
What is Hx?
400
NO KNOWN MEDICATION ALLERGIES?
What is NKMA?