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| eKardex / Patient summary screen | A patient summary screen used by many hospitals to organize essential patient information in the electronic chart. |
| Hospital information system (HIS) | The hospital software system used to document patient information, process orders, communicate with departments, track admissions and discharges, and manage hospital records. |
| CPOE | Computerized provider or physician order entry; a system in which physicians enter orders electronically so they can be processed and added to the patient chart. |
| Non-CPOE environment | A hospital environment where some or all doctors' orders are processed manually instead of being entered directly by the provider electronically. |
| Bed management | The process of tracking beds, bed availability, admissions, discharges, and transfers so patients can be placed appropriately. |
| Patient flow | The movement of patients through a health care facility efficiently and effectively, coordinating care and resources to maximize patient outcomes. |
| Right care, right place, right time | A key goal of patient flow: matching the patient with the appropriate care setting and services when they need them. |
| Patient flow department | The hospital department or team that tracks admissions, discharges, transfers, bed availability, bed type, and unit placement. |
| Bed board | An electronic bed management tool that shows bed availability, bed status, and related patient flow information. |
| Bed | In patient flow, this means more than the physical bed; it includes the services attached to that bed, such as medical, surgical, rehab, or long-term care. |
| Available bed | A bed that is physically available and has the appropriate services and staffing for the patient's care needs. |
| Bed allocator | A patient flow staff member who reviews bed availability and assigns patients to appropriate beds according to protocol. |
| Patient flow coordinator | A staff member who helps coordinate patient movement, bed status, admissions, transfers, discharges, and related communication. |
| Discharge rounds | Team meetings where patient progress, readiness for discharge, discharge plans, and bed availability are discussed. |
| Transitional rounds | Team meetings focused on patient progress, discharge readiness, and transition planning. |
| Reporting to patient flow | The clinical secretary may report pending and confirmed discharges, transfers, and unexpected discharges so the bed board stays accurate. |
| Pending discharge | A planned discharge that is expected but not yet completed. |
| Confirmed discharge | A discharge that is finalized and can be reported to patient flow when arrangements are complete and the patient has left. |
| Successful patient flow | Effective patient flow improves patient outcomes, reduces wait times, helps patients get the right bed, supports appropriate discharge destinations, and reduces hospital costs. |
| Alternative level of care | A patient status or care need where the patient no longer needs acute-care services but still requires another care setting or support. |
| ALC bed | A bed or placement for a patient who no longer needs acute care but cannot yet be discharged home or to another destination. |
| Repatriation | Returning a patient to their original or local hospital when they are stable or when an appropriate bed becomes available. |
| Interfacility movement | Movement of patients between health care facilities for care, treatment, tests, or specialized services. |
| CritiCall Ontario | An Ontario communication and referral hub that helps coordinate urgent or specialized patient transfers, bed access, and physician-to-physician consultation. |
| Emergency medical transportation service | A specialized service used to transfer critically ill patients who need advanced medical care between facilities. |
| Medical transport number | A tracking or authorization number used when arranging certain patient transfers or transportation between facilities. |
| Transfer authorization centre | A regional or provincial centre that approves transfers, assigns tracking numbers, and communicates transfer details to involved parties. |
| Patient registration / Admitting Department | The hospital area or process where patients are registered or admitted and demographic and insurance information is confirmed. |
| Admission module | The part of the hospital information system used to register or admit a patient. |
| Central name bank | A hospital database containing patients who have had encounters with the hospital. |
| Admission sheet / Face Sheet | Also called a face sheet; a document generated for any person admitted to hospital and containing demographic, insurance, admission, and physician information. |
| Medical records number (MRN) | A computer-generated hospital number assigned to the patient and used across admissions. |
| Account number | A number unique to a patient's specific admission or encounter, often used by the finance department for billing. |
| FIN number | A finance or account number associated with a specific admission or hospital encounter. |
| Hospital ID band | An identification bracelet issued on admission and encoded with patient information used for patient safety and identification. |
| RFID | Radio frequency identification; technology that may be used in a patient ID band to store detailed information read by a transponder. |
| Patient ID labels | Preprinted adhesive labels with essential patient information and barcodes, used to identify printed patient documents. |
| Missing ID band | If a patient arrives on the floor without an ID band, the clinical secretary should call admitting and have it replaced. |
| Allergy band | An additional colour-coded ID band that may be used if the patient has allergies. |
| Identifying printed documents | Any printed patient reports or forms kept in the chart must have patient labels unless the patient information is already printed on them. |
| Unlabelled chart form | A printed form without patient identification; no one should enter information on it because it could be filed in the wrong chart or lead to patient error. |
| Elective admission / Pre-booked Admission | A pre-booked or routine admission scheduled ahead of time, most often for a surgical procedure. |
| Same-day admit (ASD) | A patient admitted the day of surgery who may go to a patient-care unit postoperatively. |
| Emergency admission | An admission that usually occurs when a patient is admitted through the emergency department after assessment and triage. |
| Triage | The process of determining how urgently a patient in the emergency department needs to be seen. |
| Emergentologist | A physician in the emergency department who assesses patients and determines whether they should be admitted, treated, or sent home. |
| Obstetrical admission | An admission for a patient in established labour or with an obstetrical emergency. |
| Established labour | Confirmed labour that usually leads to admission to the obstetrical or maternal-child unit. |
| Admitting the baby | After birth, the baby is admitted separately and requires information such as identification, sex, date and time of delivery, weight, parent name, room, and doctor. |
| Outpatient admission | An admission for a patient who receives treatment or a procedure but is not admitted overnight. |
| Day surgery | A procedure where the patient is admitted for surgery or a procedure and is usually discharged the same day. |
| Accommodation coverage | The room type covered by provincial, territorial, private, or supplemental insurance. |
| Standard accommodation | Ward accommodation covered by provincial and territorial health plans. |
| Semi-private accommodation | A room type that may be covered by private insurance or selected by the patient if they accept financial responsibility. |
| Private accommodation | A private room that may be requested by the patient, ordered for medical reasons, or paid for if not covered. |
| Insurance authorization form | A form signed by a patient with private insurance authorizing the hospital to bill the insurance company. |
| Patient choice and room charges | Patients should be clearly informed when requesting accommodation not covered by their plan because they may be responsible for the cost difference. |
| eChart | The patient's electronic chart or electronic medical record generated on admission. |
| pChart | The physical binder or paper chart used to hold selected printed patient documents. |
| Populating the eChart | In CPOE, orders populate chart fields electronically; without CPOE, the clinical secretary or nurse may add the care plan and enter orders manually. |
| Chart label | The label on a physical chart that may include room and bed number, patient name, and physician name, but not diagnosis. |
| MRP | Most responsible physician; the physician primarily responsible for the patient's care. |
| Basic medical chart | A patient chart containing common fields such as admission record, orders, eMAR, vital signs, fluid balance, notes, lab reports, diagnostic imaging, and consultation reports. |
| Admission record | A common chart component containing admission information and demographic details. |
| Admitting diagnosis | The diagnosis recorded when the patient is admitted to hospital; it may be established, provisional, or differential. |
| Established diagnosis | A diagnosis made when the physician knows exactly what the problem is. |
| Provisional diagnosis | A possible diagnosis used when the physician thinks it is the most likely cause but is not fully certain. |
| Differential diagnosis | A diagnosis process used when symptoms could be caused by more than one condition and the provider must determine the actual problem. |
| Discharge diagnosis | The final diagnosis listed at discharge, which may confirm or differ from the admitting diagnosis. |
| Length of stay (LOS) | The number of hospital days the patient stayed, often recorded on the admission sheet. |
| Next of kin | The person contacted in an emergency or on the patient's behalf; this may not be the person legally authorized to make health care decisions. |
| Power of personal care | The authority to make health care decisions for a patient who is unable to do so. |
| Admission interview | A nursing assessment completed with the patient that may include health history, nutrition, sleep, activity, medications, allergies, roles, coping, and cultural or spiritual needs. |
| Doctor's orders | Physician directions for patient care, written or entered by the MRP and processed according to hospital protocol. |
| eMAR | Electronic medication administration record generated by pharmacy and used to document medication administration. |
| Vital signs flow graph | A chart section that records vital signs such as temperature, pulse, respirations, and sometimes blood pressure. |
| Parenteral therapy documentation | Documentation of intravenous therapy, including type and amount of IV fluid received and when. |
| Fluid balance record | A chart record used to track intake and output, often ordered for patients receiving parenteral therapy. |
| I&O | Intake and output; tracking everything administered to and eliminated from the patient. |
| Clinical pathway | A guideline or standard care set used to measure expected patient progress against defined goals. |
| Standard care set | Another term for a clinical pathway. |
| Multidisciplinary notes | Chart notes used by members of the health care team to document patient care, progress, and concerns. |
| Progress notes | Notes primarily used by physicians or nurse practitioners to document the patient's progress, assessment, and response to treatment. |
| Consultation report | A dictated or electronic report from a provider consulted about the patient's care. |
| Laboratory report | A report of lab test results filed in the chart; critical values may require the clinical secretary to record the call and notify the nurse. |
| Critical lab value | A serious lab result that the lab calls to the unit; the clinical secretary records the information and notifies the primary nurse or charge nurse. |
| Diagnostic imaging report | A report of imaging test results such as X-ray, bone scan, mammogram, echocardiogram, CT scan, or MRI. |
| Surgical chart | A chart for a patient having an operative procedure or invasive diagnostic procedure requiring anesthetic. |
| Surgical consent form | A required form for surgery or many procedures; the clinical secretary checks that it is signed and in the eChart or pChart before the patient goes to the OR. |
| Unsigned consent form | If a consent form is missing or unsigned, notify the nurse immediately. |
| Pre-anesthetic questionnaire | A form completed before an operation or procedure involving anesthetic to identify factors affecting anesthetic safety. |
| History and physical assessment | A preoperative assessment used to confirm fitness for surgery or identify current risk factors. |
| Missing history and physical | If the report is missing, call the family doctor's office or medical records as appropriate to locate and obtain the document. |
| Preop checklist | An inventory of essential tasks that must be completed before the patient goes to the operating room. |
| Anesthetic record | A form used by the anesthetist during surgery; it may be electronic or paper and becomes part of the surgical chart. |
| OR / Preop list | The surgical schedule sent to the floor, listing patients going to surgery and their operating room times. |
| NPO | Nothing by mouth; a status commonly ordered before surgery. |
| Preoperative orders | Orders written before surgery, sometimes time-sensitive and involving medications, tests, or assessments. |
| Preoperative medication timing | If medication is ordered one hour before surgery, the clinical secretary checks the OR time and informs the nurse of the order. |
| Current orders after surgery | When a patient goes to the OR, existing orders are usually considered void until reordered; medications are generally on hold until reordered. |
| Postoperative orders | New orders written after surgery; the clinical secretary may need to ensure they are processed and unchanged orders are reactivated according to protocol. |
| Postop bed | A bed prepared by nurses for a patient returning from surgery, arranged to ease transfer from a stretcher or gurney. |
| Post-anesthetic care unit (PAC or PACA)/ Recovery Room | The unit where patients recover after surgery before returning to the floor; formerly called the recovery room. |
| Patient valuables before surgery | Valuables may be sealed, labelled, signed over, locked away, and returned after surgery according to unit protocol. |
| Family updates after surgery | The clinical secretary may call the OR or PAC for general status or timing information and page family when the patient returns and is ready to be seen. |
| Chart confidentiality | Only members of the patient's circle of care should view the patient's pChart or eChart. |
| Unauthorized chart access | Viewing a patient's chart without being involved in their care or without permission is unauthorized access. |
| Computer tracking protocols | Hospitals can track who logs in and views patient information, so staff must secure screens and log out or lock computers. |
| Maternal-child unit security | Maternal-child units are highly secure, often using locked doors, intercom or video entry, and infant security bands. |
| Infant security band | An electronic band placed on a baby's ankle that alarms if the baby is taken near or outside exits or if the band is tampered with. |
| Patient transfer | Moving a patient from one unit to another within the same facility, usually on a doctor's order. |
| Internal transfer | A transfer from one unit to another within the same hospital. |
| Receiving unit | The unit that takes responsibility for the patient's eChart when the patient is transferred. |
| Transfer documentation | When a patient with a pChart transfers, reports and forms should be placed in a labelled envelope and sent with the patient. |
| Interhospital transfer | Movement of a patient between hospitals or facilities for treatment, diagnostic tests, specialized care, or repatriation. |
| Transportation tracking number | A number required for patient transport in many jurisdictions to track transfers and discharges to other facilities. |
| Medical authorization tracking number (MT) | A transport tracking number that may be required when arranging patient transport to another facility. |
| Transport company booking | The clinical secretary may call the transport company, provide the tracking number, arrange pickup time, and prepare required documentation. |
| Discharge | A patient permanently leaving the hospital, whether for home, a nursing home, retirement home, or another health care facility. |
| Discharge planning | A team process that identifies the patient's discharge destination, supports, follow-up, transportation, medications, and care needs. |
| Discharge destination | Where the patient goes after leaving hospital, such as home, long-term care, rehab, or another facility. |
| Discharge order | A written doctor's order required before a patient can be discharged. |
| No discharge order | If a patient says they are discharged but there is no written discharge order, tell the patient the order is not present and inform the nurse. |
| Clinical secretary discharge responsibilities | Confirm the written discharge, check expected departure time, assemble discharge information, notify departments, arrange transport if needed, and follow chart procedures. |
| Dietary services on discharge | Dietary services should be notified of discharge so meal orders can be cancelled. |
| Food tray for discharged patient | If a tray arrives for a discharged patient, send it back to the kitchen or follow unit policy for saving appropriate food items for other patients; staff should not eat it. |
| Terminal cleaning | Thorough cleaning of the bed and furniture after discharge, using disinfectant and following special protocols when required. |
| Housekeeping discharge notification | Housekeeping or physical resources should be notified promptly when a patient leaves so the bed can be cleaned and made available. |
| Discharge records | On discharge, pChart documents are handled according to facility policy, scanned or sent to health information services, and eCharts are stored electronically. |
| Discharge summary | A dictated summary required from physicians, including relevant results, medications, and discharge information. |
| Unauthorized departure / AMA | Against medical advice; A situation where a patient insists on leaving without a physician's order; the patient may be asked to sign a release form and the nurse and physician are notified. |
| Death certificate | A legally required document completed and signed by a doctor when a patient dies; it must accompany the body to the funeral home. |
| Morgue notification | The morgue, security, or porter may be called to remove the body once it has been prepared according to protocol. |
| Bereavement room | A room offered to family members if they need more time with the deceased and the body cannot remain on the unit. |
| Comfort measures | Individualized measures to keep a dying patient physically, psychologically, and spiritually comfortable. |
| Comfort measures only | A general phrase that is not enough by itself; the doctor must write specific orders for medications and interventions to discontinue or continue. |
| MAID | Medical assistance in dying; may occur in hospital and requires staff to remain objective and respectful regardless of personal beliefs. |
| Requisition | An order form requesting and authorizing diagnostic tests or other services. |
| Patient referral form | A form requesting specialized care or services for a patient through another provider or agency. |
| Community agency form | A form used to request or arrange community-based services for a patient. |
| Teaching material | Patient education information that may be printed or downloaded and given to the patient at the nurse's request. |
| Daily assignment schedule | A schedule showing staff assignments, patient assignments, breaks, and other assigned duties. |
| Staff replacement call list | A list used to call staff in proper order when a nurse calls in sick or staffing coverage is needed. |
| Float nurse | A nurse who is not assigned to a specific floor and may be sent to a unit needing extra help. |
| Transportation services records | Records or lists of transportation services and tracking numbers used for patient movement to another facility. |
| Hospital intranet | A private internal network where authorized employees access hospital information, policies, forms, resources, schedules, and learning modules. |
| Hospital policy manual | A manual containing facility policies, such as disaster response, visiting hours, work environment, and electrical equipment use. |
| Emergency Preparedness Manual | A manual kept at the nurses' station outlining policies and procedures to follow during emergencies or disasters. |
| Nursing Procedure Manual | A resource for nurses with detailed instructions for nursing procedures such as inserting tubes or monitoring head injuries. |
| Infection Prevention and Control Resource Guide | A hospital resource that explains infection prevention and control policies, including isolation policies and procedures. |
| Isolation | Keeping a patient with a contagious infection away from others to prevent spread, or protecting a vulnerable patient from infection through reverse isolation. |
| Reverse isolation | Isolation used to protect a vulnerable patient from acquiring an infection from others. |
| Emergency preparedness protocol | Hospital procedures activated for emergencies or disasters such as mass casualty incidents, floods, power outages, chemical spills, biological emergencies, or pandemics. |
