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Admission Day Surgery
Surgery scheduled the day of surgery, on patients arrival to hospital. AKA Same day surgery or Same day admit (SDA)
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Admission Orders
Written instructions written by doctor for care and treatment
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Advance Directives
Documents that indicate patients wishes in event patient becomes incapable of making decisions
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Allergy ID bands
Orange plastic band patient with what allergy printed in black sharpie.
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Census Sheet
Daily listing of all patients activity. (Admissions, discharges, transfers and deaths)
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Direct Admission
A patient who was not schedules to be admitted, and gets admitted from dr's office or clinic. (Blue Paper)
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Elective Admission
Surgery that is not an emergency or mandatory and can be planned and patients convenience.
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Emergency Admission
An admission that's processed through the emergency department
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Medical Record Number
- Number assigned to patient on or before admissions. Its used for records Id and used for all admissions to the hospital. AKA Health records number.
- example: DJ0004356
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Patient account number
- A number assigned each time patient is admitted.
- Example: DJ0008965/12
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Post Op Orders
Orders written after surgery. Post op orders cancel pre op orders
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Pre admit
process of obtaining info and partially preparing admitting forms before patients arrival
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Registration
Entering personal info into the system to enroll a person as a patient and create a patient record. Patients can be registered as impatient, outpatient, or observation patients
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Schedules medication
Given at Scheduled times
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PRN medication
as needed medication
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Medication profile goes where in chart
1st page under Dr orders
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Patient transferred in goes
under admit in chart
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patient transferred out goes
under misc. in chart
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Surgery Schedule
List of all surgeries to be performed on a particular day.
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Doctors on call schedule
List of all drs on call for specific areas
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4 types of wristbands
- Orange (allergy)
- Purple (fall risk)
- Yellow (Do no resuscitate (DNR))
- White (main ID for all patients)
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8 steps for the admitting order
- Admitting diagnosis
- Diet
- Activity
- Diagnostic test/procedures
- Medications
- Treatment Orders
- Request Old Charts
- Level status (resuscitation)
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Health records Number
1044
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10 admission guidelines
- 1. Determine appropriate room
- 2. Greet
- 3. Inform
- 4.Complete chart
- 5.locate old charts
- 6. Enter patient name everywhere
- 7. Fill in kardex and computer orders
- 8. Allergy info in appropriate areas (kardex, outside of chart)
- 9.Note code status on chart, OE and kardex
- 10. Name Alert
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5 types of discharges
- 1. Discharge home
- 2. Discharge to another facility
- 3. Discharge home with assistance
- 4. Discharge against Medical Assistance (AMA)
- 5. Expiration - A death
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Autopsy
Body examination after death
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12 Discharge Guidelines
- 1. Read entire order
- 2. Notify patients nurse, other departments, dietary, housekeeping, transport
- 3. Write on whiteboard
- 6. book appts
- 7. arrange transport
- 9. Create transfer package
- 10. Remove from census
- 12.send chart to health records
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6 transferring guidelines
- 1. Notify nurse
- 2. Notify admitting
- 3. Communicate new unit and room to nurse
- 4. Document on census, remove from floor census, send all records to new unit
- 5. Notify housekeeping
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