BTEC 222
UNIT 5 STUDY GUIDE
HUC & ORDER TRANSCRIPTION
BE ABLE TO:
1. Briefly describe the responsibilities of a health unit coordinator.
Clerical, Reception/Communication, and Coordination/Organization
2. State where a health unit coordinator works in a hospital.
The nursing station
3. State the seven steps of physician order transcription.
A. Recognize (that there is a doctor’s order)
B. Rip (paper)
C. Prioritize (important task)
STATS, this AM, Discontinued (ASAP)
D. Kardex (to be carried out by the nurse)
E. Requisition (what the doctor has ordered)
F. Symbols (documenting completion of tasks)
G. Nurse check
4. State and be able to recognize the four categories of physician orders.
1. Computer notice
2. Location of chart
3. Flagged physician order divider
4. Color coded chart
5. Describe a “kardex” form and its purpose.
NOT IN PATIENT RECORD
Kardex is a nursing tool to consolidate record of all patient treatments, medications and tests of each patient.
6. State the purpose of health unit coordinator symbols on the physician orders.
To indicate to the nurse that the work (transcription) has been completed.
7. Describe a Medication Administration Record and its purpose.
MAR is where medications orders are written onto after a physician orders them to be given. It is used to keep a
record of all medications that are given to the patient.
8. Describe a telephone order and a verbal order and how they are documented in the physician orders.
T.O. – The nurse writes a T.O. order on the physician’s order sheet. The physician then needs
to sign the order when they come into the hospital
V.O. – Physician’s order written by the nurse with V.O. after it (means that the doc told them
verbally what to do.)
9. Describe a routine order.
Physician orders preapproved by the medical staff, which are preprinted and placed on a
patient’s record. Include standard admitting orders for a surgical patient discharge orders following
surgery.
10. Provide the meaning of the following abbreviations:
T.O – telephone order
BM – bowel movement
c - with
I&O – intake & output
IV - intravenous
Neg. - negative
Tx - treatment
WC – wheel chair
V.O. – verbal order
BR or br – bed rest
s - without
+Hs – before sleep or half strength
OT – occupational therapy
ROM – range of motion
W/A – while awake
RECORDING TPRs
1. State the meaning of the abbreviation TPR.
Temperature, pulse, respiration
2. Describe what is meant by “daily TPRs”.
Take TPR daily according to hospital schedule
3. Describe what measurements are included in a Vital Sign order.
Body temperature, pulse, respiration, and blood pressure
4. Describe the TPR sheet and state why it cannot be copied and placed in a patient’s medical record.
It cannot be copied onto the patient’s medical record because the nurses use them as worksheets with all
the patient’s information on them
5. Describe a graphic record.
It is a record of vital signs on a graph.
6. Describe a flow sheet.
Columns with flow of daily information on patient – goes into record
7. Describe the proper method(s) to make a correction on a graphic record.
Put a squiggle line through the error and then initial and date it.
8. Provide the meaning of the following abbreviations:
ASAP – as soon as possible
@ - at
ht. - height
q - daily
qh – every hour
Temp - temperature
BM – bowel movement
DC - discontinue
Noc – night
qAM – every a.m.
q2h – every two hours
VS – vital signs
BP – blood pressure
Hs – at bedtime
post op – post operative
qd – every day
q4h – every four hours
wt. - weight
MEDICATION ORDERS
BE ABLE TO:
1. Define antimicrobial drugs.
Drugs used to treat a microbial infection. They include antibiotics, antifungals, antiprotozoals,
and antivirals.
2. Define pharmacodynamic drugs.
Drugs that affect the body physically
3. Define chemotherapeutic drugs.
Drugs used with specific and toxic effects upon disease-producing organisms.
4. Name the components of a medication order and be able to identify the components.
Name of the drug
Dosage of the drug
Route
Frequency
Qualifying phrase – used for “headache” and “ad lib”
5. State the three different names given to drugs and state which name is usually capitalized.
1. Chemical name
2. Generic name (lower case)
3. Brand name (capitalized)
6. State the use (or affect) of the following drug categories:
Analgesic: used for pain
narcotic – drug that has a controlled substance in it
non-narcotic – without narcotic incredients
Nonsteriodal anti-inflammatories – NSAIDS – reduce inflammation and fever
Anesthetic:
general – produces loss of sensation & muscle relaxation accompanied by loss of
conscienciousness
local – loss of sensation or “deadening” in a localized area of the body
Antianxieties – used to treat patients with anxiety problems
Anticonvulsants – used to suppress convulsions or seizures
Antidepressants - medication used to treat patients with various types of depression
Antipsychotic – major tranquilizers used to relieve symptoms of psychoses or severe neuroses
Hyponotics - used to promote sleep
sedatives – used to relax
Stimulants – used to stimulate the CNS
Insulin – used to aid in the metabolism of sugars in diabetics
Corticosteroids – used for anti-inflammatory and immunosuppressant properties
Hormones – used for the replacement of hormones for the prevention of osteoporosis in post-menopausal
women
Antihistamines – helps to relieve allergic symptoms by countering histamines in the body
Antitussives – relieves coughing
Bronchodilators – dilates the bronchioles in the lungs, used in the treatment of asthma
Expectorants – used to help break up the mucus in the lungs
Antacids – used to reduce acidity of gastric secretions
Anticholinergics – drug that blocks the action of the parasympathetic nervous system
Antidiarrheals – used to reduce the number of loose stools
Antiemetics – used to prevent or treat nausea, vomiting, or motion sickness
Cathartics – used to promote bowel movements
Emetics – used to produce vomiting; syrup of ipecac
Antianginals – used to relieve the symptoms of angina pectoris (severe chest pains)
Anticoagulants – used to prevent formation of clots or decrease the extension of existing clots
Antidysrythmics – misnomer of anti-arrhythmias – used to prevent or alleviate arrhythmias
Antihyperlipidemics – used to treat hyperlipidemia (high cholesterol)
Antihpertensives – used to treat high blood pressure
Cardiotonics – an agent that has a tonic effect on the heart – strengthens the heart
Diuretics – increase urine output
Thrombolytics – used to dissolve clots after they have formed
Vasodilators – used to expands the wall of the blood vessels resulting in increased blood pressure
Antiarthritics – used to treat the symptoms of arthritis & other related diseases
Muscle relaxants – used to relax muscles from spasms of skeletal muscles
7. Describe the affect of the antimicrobial drug categories.
They are drugs that fight fungi, parasites, virus and bacteria
8. Describe what is meant by therapeutic drug monitor.
The measurement of specific drugs at intervals in order to maintain a relatively constant
concentration of the medication in the bloodstream.
9. Define the abbreviation for the following pharmaceutical preparations:
Ampules – amp
Spansules - spans
Capsules - cap
Suppository - supp
Elixir – elix
Tablets - tab
Enteric coating - EC
Troches, lozenges – troche
Extract - ext
Others:
drops - gtt
Liniment - lin
milliequivalent - mEq
Liquid - liq
teaspoon - tsp
Lotion – lot
tablespoon - tbsp
Ointment - ung
unit - U
Powder - pul
10. Define metric measures and interpret basic apothecary measures.
Metric measure - Based on multiples of 10. This makes it easier to calculate dosages.
Apothecary – Current usages but being phased out – more complicated with use of grains, drams & oz
11. Define the routes of administration:
Oral – by mouth
Sublingual – under the tongue
Inhalation - inhaled
Topical – applied on the skin
Parenteral:
intramuscular – given within the muscle
subcutaneous – given under the skin
intradermal – given into the skin
intravenous – given into the vein
intravenous piggyback (IVPB) – 2 lines with 2 different solutions @ same time into one IV
12. Describe an intravenous push (IVP or IV-P).
Medication that is given by syringe directly into an IV line
13. Define the following routes of administration abbreviations:
AD – right ear
AS – left ear
AU – both ears
H - hypodermic
IM - intramuscular
IV - intravenous
IVP – intravenous push
OD – left eye
OS – right eye
OU – both eyes
p.o. – by mouth
subling - sublingual
subqu - subcutaneous
14. Describe a heparin lock.
Small tubes attached to a catheter, inserted into the arm and held in place with tape in order to
administer drugs and fluids without injecting patients multiple times unnecessarily.
15. Describe a PCA device.
Patient controlled analgesic device. Pain medication that is administered by the patient as they feel they need it
(only a set amount is allowed per hour)
16. Be able to convert from clock time to European or military time and back.
17. Define the following times of administration abbreviations:
qod – every other day
qd – every day
bid – Two times daily
tid – Three times daily
qh – every hour
q_h – every (however many) hours
hs – at bedtime
ac – before meals
pc – after meals
stat – at once, without delay
prn – as needed
sos – if there is a need, may be repeated once if
necessary
18. Describe an “automatic stop” related to a stop order.
Some drugs have an automatic stop date (controlled substances, potent drugs) that stop automatically and need to
be written again to start again
19. Describe the transcription of a “change order” and a “discontinue order”.
Change order – Changing a previous orders frequency, route, or dosage. It is considered a “NEW” order.
Discontinue order – Order that discontinues the use of an order
20. State what the numbers assigned to analgesics containing Codeine indicate.
#1 – 7.5mg, #2 – 15mg, #3 – 30mg, #4 – 60mg
21. Read and understand medication orders.
NURSING PROCEDURE ORDERS
BE ABLE TO:
1. Briefly define the following:
Catheter – used to remove urine from the bladder
Intake and Output – food or fluid taken in and food or fluid that comes out
Normal saline solution – saline solution that has not other properties but saline
Traction – leg in a sling with pressure – for fractures
2. Describe a nasogastric tube/Levin tube (NG tube).
It is a tube that is placed up the nose, down the throat, and into the stomach.
It is used for feeding and irrigation (washing out) of the stomach
3. Identify the abbreviations related to the following bowel orders:
TWE – tap water enema
SSE – soapsuds enema
NSE – normal saline enema
OR enema – oil retention enema
Fleet or Travad enema – disposable enema
4. Describe a colostomy and colostomy irrigation.
Colostomy – Creating an opening into the colon
Colostomy irrigation – flushing of fluids to clean out the opening to the colon
5. Discuss moist and dry application and types:
Moist - soak – warm or cold, compress – warm or cold, tub, sitz bath
Dry - ice pack and ice collar, heat lamp, aquamatic K-pad, thermal blanket
6. Describe the purpose of urinary catheterization.
Used on patients who are unable to urinate due to surgery or other reasons
7. Describe a retention (indwelling or Foley catheter) and non-retention catheters.
Retention – It is inserted into the bladder and kept in place with an inflated balloon
Non-retention – It is a “straight” catheter used for taking a sterile urine sample (goes in and comes out)
LAB AND DIAGNOSTIC IMAGING
BE ABLE TO:
1. Identify the major laboratory departments and describe their functions.
Hematology – The study of the blood itself
Chemistry – The study of the components in the blood
2. Give a short description of the following hematology tests and know the abbreviations.
Complete blood count (CBC) - all component blood test – WHOLE #s
Hematocrit (hct)/ Packed Cell Volume (PCV) – red blood cells as a % in a volume of blood (for anemia)
Hemoglobin (hgb) – hemoglobin test for protein in the blood
White Blood Count (WBC) – total white blood cell count
Differential (Diff) - % of the total WBC made up by different types of leukocytes
Red Blood Count (RBC) - whole number count of red blood cells
Reticulocytes (Retics) – measure of immature red blood cell count in blood
Sedimentation Rate (sed rate) (ESR) - Erythrocyte sedimentation rate
Red Blood Cell Indices (RBC indices) – tests to measure the bloods ability to carry oxygen to the cells
3. Name the three methods of obtaining a urine specimen and give short description of each.
1. Voided
2. Clean Catch
3. Catheterized (cath UA)
4. State the purpose of the following chemistry tests and know abbreviations:
Electrolytes (Lytes) - used to screen for an electrolyte or acid-base imbalance & to monitor the effect of treatment
on a known imbalance that is affecting bodily organ function
Bilirubin (Bili) – used to detect if bilirubin is adequately being removed from the body – increased bilirubin
causes jaundice
Fasting blood sugar (FBS) – measures blood glucose after you have not eaten for at least 8hours
Glucose Tolerance Test (GTT) – test to check how fast the level of glucose is cleared in the blood
Iron (Fe) – level of iron in the blood
Blood Uria Nitrogen (BUN) – used to evaluate kidney function and to help diagnose kidney dysfunction or failure
SGOT (APT) – used to test for liver damage
SGPT (ALT) – used to test for hepatitis
LDH – Lactate dehydrogenase levels in the blood - used for MI infarction
CPK – high creatine phosphokinase levels in the blood can indicate injury or stress to the heart, brain, or muscle
tissue - used for MI infarction
Alk Phos – high levels of alkaline phosphatase can indicate liver damage
Uric acid – used to determine if the body is breaking down cells too quickly or not getting rid of uric acid
quickly enough – used to determine if you have gout
5. List the four divisions of microbiology.
1. Bacteriology
2. Mycology
3. Parasitology
4. Virology
6. Describe the following abbreviations:
C&S – Culture and Sensitivity
T&C – type and cross match
O&P – ova and parasite
CC – cubic centimeter
AP – anterior/posterior
PA –posterior/anterior
BE – barium enema
CT Scan – computerized tomography scan
GI - gastrointestinal
IVP – intravenous push
KUB – kidney, ureter, bladder
MRI – magnetic resonance imaging
UGI – upper gastrointestinal
US – ultrasound
QUESTIONS JOHN ASKED IN THE MORNING, BUT NOT ALL ARE ON HERE THAT HE ASKED!!