Glossary

legal documents that communicate a person’s wishes about health care decisions in the event they become incapable of making health care decisions (either permanently or temporarily)

main document of the intraoperative course of anesthesia administration;  completed by the anesthetist

a group within a large trade union that negotiates or "bargains" the terms of employment for a particular category of worker, such as nurses

responsible for the placement, transfer, and discharge of all inpatients, emergency patients, and patient transfers according to priority and preferred accommodation status; often works closely with a RN (or patient flow manager) in their duties.

pre-developed guide to ensure that patients receive consistent care, minimally acceptable standards are met, and nurse's time is used efficiently; standard care plans provide the same interventions for all patients, without account of the patient's diagnosis

documenting only significant deviations from the norm; assumes everything is normal unless noted

a dedicated phone (often red) or a dedicated phone line used to directly contact the switchboard in case of an emergency

the contract agreed to between the union and the employer

the process of negotiating the employment contract between union members and the employer

process in which a physician directly enters orders into the patient chart; replaces handwritten orders on an order sheet or prescription

written form a patient signs before a surgical procedure

a second physician’s written opinion based on an examination of the patient and a review of the patient’s health record

set of questions asked during the registration process, such as name, DOB, insurance, providers, medical alerts

a pre-developed guide that outlines the appropriate sequence of clinical interventions, timelines, milestones, and expected outcomes for patients with a specific diagnosis, such as fractured hip or bowel resection

reports from tests completed in the hospital's diagnostic imaging department, including x-ray reports, ultrasound reports, nuclear medicine reports, mammography reports, MRI and CT reports, etc.

an inpatient hospitalization where a patient is not electively pre-booked for a procedure and does not go through the hospital's ER department for assessment; usually transfers from other facilities or immediate admission from a specialist's office

a physician's order to release a patient from a health care facility

a concise record of the patient's clinical progress in the hospital; required for all patients regardless of length of stay

a form where doctors record all orders related to the patient; including blank and pre-printed forms for standard procedures

reports resulting from electrocardiograms

surgical procedures that are scheduled in advance by the surgeon's office

admissions that occur through the emergency department

a system for notifying all staff of an major emergency, which makes direct contact and uses a script

any visit where a patient receives medical treatment, testing, evaluation and/or management services within any area of the hospital; for example, a patient encounter may be a CT scan, an ER visit, or an inpatient admission for a mastectomy

resulting from a patient's visit to the emergency department and documents the care received during their emergency stay

initial record produced from the registration process

assesses how likely it is that a patient—usually an older adult—may fall; the Morse fall scale is the most common

financial number

hospital departments that support patient care but do not provide patient care; usually administrative, informational, regulatory, or environmental

indicates patient with diabetes; can be used in combo with red if patient with diabetes has allergies

a formal allegation reported to the union that the employer has violated the collective agreement

formal report resulting from the physician's interview with the patient, the physical exam, and the summary of the testing either obtained or pending

hospital number

a term for the health office administrative role within hospitals; also called health unit coordinator, communication clerk, clerical associate, unit clerk, or clinical secretary

hospital departments that provide clinical care to patients registered for more than 24 hours; the type of care to length of stay may vary greatly, from overnight surgery to extended critical care; however, patients remain under the supervision of a nurse or doctor

report from any tests completed in the hospital's laboratory

the act of witholding consent for disclosure of PHI for health care purposes; comes from the practice of putting important documents into a small box that can be secured with a lock and key

a table or database that includes patient information used in registration and billing processes; each individual patient within the database has a unique identifier

forms that nurses use to document all medications given to a patient

medical record number

a running log of everything that happens with patient during a shift; chronological, concise, objective

hospital-related infections that were not present on patients when admitted; may also be present on patients who have recently been admitted to hospitals or long-term care facilities

specific to women giving birth; whether vaginally or surgically

detailed account of the patient’s procedural or operative encounters

block of operating room time the hospital allocates for a surgeon to use for surgical procedures; typically half-days or full-days

a form used to assist nursing staff in preparing the surgical patient for their procedure

indicates patient with risk of falling; used in addition to a regular armband

departments that provide clinical services for less than 24 hours; services range from tests and scans, to treatments and day surgery

pre-printed sheets of labels containing key demographic, clinical and billing information for the patient; affixed to documents in the p-Chart

questionnaire completed by the patient/patient's family prior to the surgical procedure

when a single nurse handles all the needs of their assigned patients

main form of communication between physicians and other staff; the physician typically documents on this record after each interaction with the patient, outlining their progress, prognosis and plan of treatment

the unit census plus the anticipated discharges, anticipated elective admissions, waiting ER patients, and pending transfers

indicates patient with known allergies

a structured charting system that organizes notes into four sections: subjective, objectives, assessment, and plan

form to book patient surgical procedures at a hospital, originating in the specialist's office and sent to the hospital's OR bookings department

when a group of health care workers, such as RNs, RPNs, and PSWs, work together to care for different needs of their assigned patients

thorough cleansing of a patient area, including bed frame, mattress, side table, and curtains, with a disinfect solution

specialist level of care, usually in a hospital setting, often over an extended period of time, such as dialysis, surgery, or psychiatric treatment

process of removing documents older than a certain date and moving them into a separate secondary record known as the overflow record

an organization of workers in a particular trade or industry that join together to improve working conditions and terms of employment

to be a member of a union or a workplace required to follow the rules of a union

a count of the actual number of patients on a unit

health information management best practice where hospital personnel rely on the use of chart order guides (or tabs) that are arranged in a consistent fashion

indicates patient without known allergies or diabetes