Chapter 8: The Patient’s Paper Chart or Electronic Record Key Terms and Abbreviations
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admission packet
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a preassembled packet of standard chart forms to be used on admission of a patient to the nursing unit
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allergy
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an acquired, abnormal immune response to a substance that does not normally cause a reaction; may include medications, food, tape, and many other items
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allergy bracelet
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a plastic bracelet (usually red) that is not worn by a patient that indicates allergies they may have
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identification labels
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labels that contain individual patient information for identifying patient records or other personal items
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imprinter cards
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small plastic cards with individual patient information used to identify patient records(used in some hospitals in place of identification labels)
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allergy labels
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labels affixed to the front cover of a patient's paper chart that indicates a patient's allergies
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imprinter machine
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a machine used to imprint information from patient indentification imprinter cards onto chart forms
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name alert
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a method of alerting staff when two or more patients with the same or simarily spelled last names are located on a nursing unit
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old record
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a patient's paper record from previous admissions stored in the health inforamtion management department that may be retrived for review when a patient is admitted to the emergency room, nursing unit, or outpatient department; older microfilmed records also may be requested by the patient's doctor
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\"split\" or thinned chart
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portions of the patient's current paper chart that are removed when the chart becomes so fulled that it is unmanageable
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standard chart forms
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forms included in all inpatient paper charts that are used to regularly enter information about patients
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stuffing charts
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placing extra chart forms in patients' paper charts so they will be available when needed
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supplemental chart forms
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patient chart forms used only when specific conditions or events dictate their use
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WALLaroo
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a locked workstation that is located on the wall outside a patient's room; it stores the patient's paper chart or a laptop computer , and when unlocked, it forms a shelf to write upon
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H&P
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History and Physical
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Hx
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History
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ID labels
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Identification Labels
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MAR
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Medication Administration Record
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NKA
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No Known Allergies
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NKFA
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No Known Food Allergies
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NKMA
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No known Medication Allergies
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NKDA
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No Known Drug Allergies
