Nursing Unit Clerk Communications Vocabulary

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clinical tasks

Back 1

tasks performed at the bedside or in direct contact with the patient

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computer physician order entry

Back 2

a computerized program into which doctors directly enter patient orders

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doctor

Back 3

person licensed to practice medicine

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electronic medical record (EMR)

Back 4

electronic record of patient health information generated by one or more encounters in any care delivery setting

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doctors orders

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The health care that a doctor prescribes in writing for a hospitalized patient

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hospital departments

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divisions within the hospital that specialize in services

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non clinical tasks

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tasks performed away from the bedside

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nursing station

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The desk area of a nursing unit

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nursing team

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a group of nursing staff members who care for patients on a nursing unit

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patient Pt

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a person who receives health care

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policies and procedures

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information such as guidelines for practice and hospital regulations found online or in a manual

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transcription

Back 12

a process used to communicate the doctors to the nursing staff and other hospital departments; computers or handwritten requisition are used

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accreditation

Back 13

recognition that a health care orginization has met an official standard

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community health

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field concerned with the members of a community with emphasis on prevention and early detection if diease

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Home health

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equipment and services provided to patients in their homes to ensure comfort and care

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hospice

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supportive care for terminally ill patients and their families

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Long term care LTC

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a variety of services, often provided in non hospital settings, that help meet both the medical and non medical needs of people with a chronic illness or disability who cannot care for themselves for long periods of time

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acuity

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level of care patients would require on the basis of their medical condition

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acute care

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level of health care generally provided in hospitals or emergency departments for sudden, serious illnesses or trauma

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assignment sheet

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a form completed at the beginning of each work shift that indicates the nursing staff members assigned to each patient

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attending physician

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term applied to a physician who admits and is responsible for a hospital patient

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chronic

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long-lasting: describes an illness or medical condition that lasts over a long period and sometimes causes a long term change in the body

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hospitalist

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full time, acute care specialist who focuses exclusively on hospitalized patients

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inpatient

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patient wo receives medical or surgical care whose doctor has written an admission order

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interdisciplinary teamwork

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Well coordinated collaboration among health care professionals toward a common goal

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lpn

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a graduate of a 1 year school of nursing program who is licensed in the state in which he or she is practicing. provides direct care and functions under the direction of the registered nurse

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nurse manager

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a RN who assists the director of nursing I carrying out administrative responsibilities and is in charge of 1 or more units

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outpatient

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a patient receiving medical or surgical care while registered as an outpatient and whose primary physician has not written an admission order

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patient care conference

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Meeting of a patient's doctor or resident primary nurse case manager or social worker and other health care professionals for the purpose of planning the patients care

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Perioperative services

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Department of the hospital that provides care before during and after surgery

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registered nurse

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graduate of a or 4 year college based nursing program or a 3 year hospital program who is licensed in the state in which they are practicing

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shift manager

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RN who is responsible for one or more units during his or her assigned shift. May also be called nursing coordinator or charge nurse

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staff development

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department responsible for orientation of new employees and continuing education of employed nursing service personnel

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team leader PCC patient care coordinator

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RN who is in charge of a nursing team

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triage

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nursing interventions. classifications defined as establishing priorities of patient care, usually according to a 3 level model; emergent, urgent, and non urgent

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bulletin boards

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2 or more boards that may be present on a nursing unit, including one for education and policy changes, and one for personal information for nursing staff

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Census board

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Whiteboard usually in the nurse's station area on which to report census information including unit remembers admitting doctor's name and the name of the nurse assigned to each patient

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Doctors roster on call

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Alphabetical listing of names telephone numbers and directory telephone numbers of the physicians on staff

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Downtime requisition

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A paper order form that is used to process information when the computer is not available for use

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dumb waiter

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A mechanical device for transporting food or supplies from one hospital floor to another

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Label printer

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Machine that prints patients labels from information entered into the computer located near the Health Unit coordinators area

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Mass communication system

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A system that in an emergency can quickly and efficiently deliver messages to tens hundreds or thousands of recipients

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Patient call system intercom

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Device used to communicate between the nurses station and patients room on the nursing unit

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Pneumatic tube system

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A system in which air pressure transports to carrying supplies some lab specimens and some medications to and from hospital unit or department

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Pocket pager

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Small electronic device that when activated by entering a series of numbers into a telephone delivers a digital or voice message to the carrier of the picture

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Voice paging system

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System by which the hospital telephone operator pages a message for a doctor or makes other announcements the system reaches all hospital areas used only when absolutely necessary to keep noise level down

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Workstation on wheels wow

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Mobile computer that can be taken to a patient's bedtime allowing nurses and other healthcare professionals the ability to access and enter information into patient records

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Code of Ethics

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A set of rules and procedures for professional conduct based on the values and ethical standards of an organization or profession

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Confidentiality

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A legally protected right afforded to all patients of having personal and medical information be protected

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Ethics

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A system of moral principles the leaves that determine how we make judgments in regard to right and wrong

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Informed consent

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Doctrine that states that before patients are asked to consent to a risky or invasive diagnostic or treatment procedure they are entitled to restrict certain information.
1 a description of the procedure
2 any alternatives to it and their risks
3 risks of death or serious bodily disability from the procedure
4 probable results of the procedure including any problems with recuperation and anticipated time of recuperation
5 anything else that is generally disclosed to patients who were asked to consent to a procedure

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Scope of practice

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Legal description of what a specific health professional may and may not do