Chart Dividers & Forms
Where would I find the Orders and Directives form in the patient chart?
Physician Orders
What do you need to do for a unit to unit transfer? ( you are the sending unit)
Make sure all orders are complete
Book a porter
Send the chart with the porter
Notify Bed Booking
CBR
Complete Bed Rest
Your patient asks you if they can go home for the night and come back tomorrow.
What do you do?
Ask the patient to request a day pass from the doctor.
A Routine/Elective admission occurs when the patient and doctor decide when to schedule a nonemergency surgery or procedure, and it is planned in advance.
True
Give me 2 things you could find at the front of the patients chart?
Medical Certificate of Death
Master Signature Sheet
Screening for MRSA & CPO
Risk Profile
Client Waiver & Release of Responsibility
A patient gets transferred to your unit, what is the first thing the clerk does?
Notify the primary nurse (nurse assigned to the patient)
DAT
Diet as Tolerated
You get an order to thin a patients chart. What can you thin from the patients chart?
nurses notes
MAR's
graphic records
NEVER the doctors orders!
A patient is transferred to a unit in the same hospital, the chart for that patient stays on the unit and the contents gets faxed to the new unit.
False.
We send the chart with the patient to the new unit.
What could you find under the Report of Operations divider?
Preoperative Checklist
Operative Report
Consent for Healthcare
Your patient expires on your medical unit, what steps does the clerk need to take?
print of the death pack and put in front of the chart for the nurse/doctor, book a porter to the morgue, send the chart with the porter (once the certificate of death is completed)
MRP
You just got on shift and a porter arrives and says he's here to pick up a patient for a scan. You know nothing about this, what would you do?
Ask for the patient information
Check the Kardex for that patient
(Can also confirm with the nurse as last resort)
Your patient is being discharged with a prescription and a discharge summary. It is the unit clerks job to have this ready for the patient to pick up on their way out.
True!
Give me 2 examples of forms you could find under the Diagnostic Section in the chart?
X-Ray Report
CT Report
MRI Report
Ultrasound Report
PET Scan Report
You are transferring a patient to a long term care facility, what does the clerk need to send to the receiving unit? (list as many as you can)
MOST (Code Status)
recent physician’s orders
discharge/transfer prescription
48/6- discharge planning tool
the most recent physician progress notes
nurse’s notes and vitals record
MAR
any discharge follow-up appointment information.
MAR
Medication Administration Record
Your nurse comes up to you to ask where their patient went. Another nurse says, "Oh I saw him leave about an hour ago with all his stuff"
What does the clerk do?
Hold the bed and chart on the unit for 24hours, mark the patient as LAMA discharge in the system after that.
When disassembling a patient chart you need to file the contents in a specific order
False! no specific order, just make sure its all there.
Where can I find the Braden Scale Assessment Interventions Flow Sheet in the chart?
Nurses Notes
An AMA discharge patient needs to sign which form?
A Hospital Waiver Form
DX
Diagnosis
A patient on your unit yells "I'm leaving, what do I need to do to get out of this place!!"
What would you do as the clerk
Make the nurse aware, print of the release of responsibility to be signed by the patient and witness.
In patient appointments are booked but the patients
False, booked by the clerk