Fundamentals of Medical Orders

This reflective essay analyses the roles and responsibilities of a hospital unit clerk (HUC) with a special mention to the medical orders transcription and processing. It highlights the importance of proper transcription of medical orders in reducing medication errors and improving healthcare quality.

Running head: FUNDAMENTALS OF MEDICAL ORDERS
Fundamentals of Medical Orders
Name of the Student
Name of the University
Author Note

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FUNDAMENTALS OF MEDICAL ORDERS
Hospital unit clerk (HUC) mainly address inquiries at the main desk of the unit, they
also act as organisational public relations executive while providing efforts to improve the
quality of healthcare. The following reflective essay aims to analyse the roles and the
responsibility of HUC with a special mention to the medical orders transcription and
processing
Within my scope of practice as a HUC, the topic which I found most interesting is
transcribing and processing of medical orders. Apart from finding it interesting, I also found
it extremely curial in healthcare domain. According to Mailman, Betcher and Semchuk
(2017), medication errors are leading cause of mortality and morbidity which again increase
the overall healthcare cost and improper transcription of the medical orders is a major
contributor of medication error. I feel distractions occurring during transcriptions and the
communication problems are main reasons behind medication errors associated with
transcribing and processing of medical orders.
From the content I have understood that it is the role of the HUC to play an active
role transcription, processing and dispensing of medicines. My scope of practice notified me
further that I should be equipped with the required knowledge and skills of the medication
management in order to reduce the chances of medication errors and thereby promoting
safe healthcare practice. Apart from medical order transcription, HUC also has
administrative role. HUC is required to keep a track of medical charts and update it
accordingly. HUC also performs medical assisting like recording temperature, blood pressure
and pulse rate of the patients. The Liaison duties include point of contact of the staff
members of one department when there is a need to transfer important medical
information to another staff member to different medical department. HUC is also required
to perform standard secretarial duties (Kassam, Kwong & Collins, 2013).
From my understanding, it is clear that the role of HUC is diverse however, the role
which I feel is important for uplifting the quality of the healthcare service is proper
transcription of the medical orders in order to reduce the possible chances of medication
errors. Assurance of quality health and safety is the main scope of practice of HUC. of The
process of medication order transcription starts with the transcription of the medical orders,
prescribed by the doctors over official papers chart. After the medication orders are written,
those medication charts are required to be forwarded to the dispensary pharmacist for
further review. The reviewed document will again be reviewed by HUC to iron out errors
and then double checked by the nursing staffs (Tshiamo et al., 2015).
Knowing and working within the scope of practice helps the HUC to provide
invaluable administrative support to the clinics, clinical care units and multidisciplinary
healthcare professionals. HUC scope of practice also constitutes execution of administrative
tasks, answering of the phone call in a timely manner and processing of the physicians order
over phone (Kennedy, 2016). I also feel that proper clerical support coming from the HUC to
the nursing professionals’ further help to regularize the overall process of healthcare and
thereby improving quality in health.
For example, proper transcription of the medical orders by HUC, reduce one part of
job stress from the shoulders of the nursing professionals and at the same time helps to

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FUNDAMENTALS OF MEDICAL ORDERS
reduce the chances of the medication error. Alternatively, it can be said that reduction in
the job stress helps to reduce the medication errors (medication administration among the
nursing professionals) (Parry, Barriball & While, 2015).
According to Kennedy (2016), HUC, is regarded as the first point of contact by the
family members of the patients and thus regarded as an integral link in the healthcare
organization's public relations. However, I think working beyond the scope of practice via
taking extra initiatives will help to improve the overall quality of care. For example,
interacting directly with the patients and transferring the information of the patients to
their family members through daily interactive session will help to improve the overall
patient outcomes as patient will feel that that hospital authority is concerned with his or her
condition (Kramer et al., 2015). Moreover, I also feel that a HUC must also take extra
initiative in transcribing and processing of the medical orders via cross checking the
information twice. In doing this will reduce certain amount of workload from the nursing
professionals and will help to reduce medication error (Parry, Barriball & While, 2015).
First tool that I will suggest for the medicine order entry is computerised physician
order entry (CPOE) system. This will help to reduce the chances of medication error arising
out of poor hand writing of the physicians or incomprehensible verbal transcript of the
doctors (Schiff et al., 2015). Second tool that I will suggest is headphones this will help to
reduce the external noise disturbances making the doctors instructions easy to decipher.
Third tool will be online transcription tool. This will help in automatic transcription (Schiff et
al., 2015). However, as a HUC, I will cross-check the generated written transcript in order to
reduce the technical errors if any.
Thus from the above discussion it can be concluded that the HUC plays a pivotal role
medical order transcription and processing. However, taking help from the automated tools
will help to reduce the workload and at the same time will help to increase the accuracy of
the outcome.

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FUNDAMENTALS OF MEDICAL ORDERS
References
Kassam, R., Kwong, M., & Collins, J. B. (2013). Role-emergent model: an effective strategy to
address clinical placement shortages. Internet Journal of Allied Health Sciences and
Practice, 11(4), 4.
Kennedy, M. (2016). The Importance of a Role-Specific, In-Hospital Ward Clerk Education
Program. Hospital topics, 94(3-4), 43-48.
Kramer, U., Pascual-Leone, A., Rohde, K. B., & Sachse, R. (2016). Emotional processing,
interaction process, and outcome in clarification-oriented psychotherapy for
personality disorders: A process-outcome analysis. Journal of personality
disorders, 30(3), 373-394.
Mailman, J. F., Betcher, J., & Semchuk, W. (2017). Ensuring Accurate, Timely Medication
Orders and Reducing Errors: Assessment of a Read-Back Tactic. The Canadian journal
of hospital pharmacy, 70(5), 395.
Parry, A. M., Barriball, K. L., & While, A. E. (2015). Factors contributing to Registered Nurse
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studies, 52(1), 403-420.
Schiff, G. D., Amato, M. G., Eguale, T., Boehne, J. J., Wright, A., Koppel, R., ... & Bates, D. W.
(2015). Computerised physician order entry-related medication errors: analysis of
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Tshiamo, W. B., Kgositau, M., Ntsayagae, E., & Sabone, M. B. (2015). The role of nursing
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