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Surgery in which the patient enters the hospital the day of surgery; it may be called same-day surgery or AM admission |
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Written instructions by the doctor for the care and treatment of the patient upon entry into the hospital |
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Admission Service Agreement or Conditions of Admission Agreement |
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A form signed upon the patient's admission that sets forth the general services that the hospital will provide; it may also be called the conditions of admission, contract for services, or treatment consent |
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Documents that indicate a patient's wishes in the event that the patient becomes incapacitated |
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Allergy Identification Bracelet |
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A plastic band with a cardboard insert on which allergy information is printed or a red plastic band that has allergy information written directly on it that the patient wears throughout the hospitalization |
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Information obtained from the patient concerning his or her sensitivity to medications and/or food |
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Blood Transfusion Consent |
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A patient's written permission to receive or refuse blood or blood products |
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A list of all occupied and unoccupied hospital beds |
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A patient who was not scheduled to be admitted and is admitted from the doctor's office, clinic, or emergency room |
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Surgery that is not emergency or mandatory and can be planned at a time of convenience |
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An admission necessitated by accident or a medical emergency; such an admission is processed through the emergency department |
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A form initiated by the admitting department included in the inpatient medical record, which contains personal and demographic information, usually computer generated at the time of admission (may also be called the information sheet or front sheet) |
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The number assigned to the patient on or before admission; it is used for records identification and is used for all subsequent admissions to that hospital (may also be called medical records number) |
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The duty to inform a patient before obtaining a signature of permission |
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A declaration made by the patient to family, medical staff, and all concerned with the patient's care stating what is to be done in the event of a terminal illness; it directs the withholding or withdrawing of life-sustaining procedures |
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A patient who is assigned to a bed on the nursing unit to receive care for a period of less than 24 hours; may also be referred to as a medical short-stay or ambulatory patient |
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A number assigned to the patient to access insurance information, usually a unique number is assigned each time the patient is admitted to the hospital |
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Patient Identification Bracelet |
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A plastic band with a patient identification label affixed to it, which is worn by the patient throughout hospitalization. In the obstetrics department, the mother and baby would have the same identification label affixed to their ID bracelets |
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Orders written immediately after surgery. Postoperative orders cancel preoperative orders |
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Power of Attorney for Health Care |
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The patient appoints a person (called a proxy or agent) to make health care decisions should the patient be unable to do so |
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The process of obtaining information and partially preparing admitting forms prior to the patient's arrival at the health care facility |
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Preoperative Health Unit Coodridnator Checklist |
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A checklist used by the health unit coordinator to ensure that the patient's chart is ready for surgery |
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Preoperative Nursing Checklist |
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A checklist used to ensure the chart and the patient are properly prepared for surgery |
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Orders written by the doctor before surgery to prepare the patient for the surgical procedure |
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The admitting personnel who registers a patient to the hospital |
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The process of entering personal information into the hospital information system to enroll a person as a hospital patient and create a patient record; patients may be registered as inpatients, outpatients, or observation patients |
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A patient admission planned in advance; it may be urgent or elective |
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A patient's written permission for an operation or invasive procedure |
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A list of all the surgeries to be performed on a particular day; the schedule may be printed from the computer or sent to the nursing unit by the admitting department |
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A container for storing the patient's jewelry, money, and other valuables, which are placed in the hospital safe for safekeeping |
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outpatient surgery (ambulatory surgery) |
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