Fundamental of Medical Orders: Role of Hospital Unit Clerk in Record Keeping and Transcription

This article discusses the role of hospital unit clerks in record keeping and transcription of medical orders. It emphasizes the importance of working within one's scope of practice and the impact of working outside it. The article also provides tools to use to stay within one's scope of practice.

FUNDAMENTAL OF MEDICAL ORDERS 1
REFLECTION SUMMARY OF A HOSPITAL UNIT CLERK
Name:
Institutional affiliation:
Designation:
Student ID:
Course title:
Instructor’s name:

FUNDAMENTAL OF MEDICAL ORDERS 2
INTRODUCTION
Hospital unit clerks are among the various professionals who work in the hospital in
collaboration with other health care workers. Health records are important in the hospital since
they provide evidence regarding the patients' stay in the hospital. Health records are also kept
private and confidential for the patient’s privacy(Mandl, Markwell, MacDonald, Szolovits and
Kohane,2011). Hospital unit clerks play an important role of record keeping of the patient’s
documents, transcribing laboratory and medical orders. This emphasizes the important role of
hospital unit clerks since documents play an important role in communication between
different healthcare workers in the hospital.
INTERESTING TOPIC
The most interesting topic for me was how to prepare the documents for medical orders
and transcription. Transcription is interesting as it involves putting a physician’s orders
according to your own understanding into different forms (Wang et.al 2011). Learning new
medical terminologies without changing their meaning and using technology to enhance it is
informative. One also keeps abreast of various trends in both technology and medical sector so
you are able to perform at optimum. I think it is valuable since it eases communication between
different medical departments without misinterpretation.
COURSE CONTENT
The course content in fundamentals of medical orders has helped me in understanding
the role of hospital clerk in that it goes into deeper details regarding the preparation of
requisitions of tests and treatments. The course also explains the role of the hospital unit clerk
in transcription and processing of medical orders and administrative procedures in admission
and discharge.
SCOPE OF PRACTICE
Hospital unit clerks are involved in handling patient records and providing data on
request for research. A hospital unit clerk is charged with overseeing other clerical workers and
the medical records in general. Maintenance of patient’s records ensuring their privacy and
confidentiality. They are involved in providing medical data for patients to physicians, nurses,
and other healthcare workers. The input of data into the computerized systems is done by the
hospital unit clerk and prompt modification during admission and discharge. Billing by
insurance companies is conducted by the clerk and the entry of data such as the progress of
disease and laboratory procedures done. This relates to transcribing and processing medical
orders in that hospital unit clerks are trained in medical terminology and use of Microsoft office
suite in the healthcare system. They are able to type and edit different medical orders in the
right medical formats

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IMPORTANCE OF WORKING IN YOUR SCOPE
It is important to know your work of scope of practice since involves increased
productivity in doing your activities within your designation. Working within one’s scope of
practice increases their performance since they have been trained and accredited in various
activities such as medical records. A hospital unit clerk is psychologically prepared for the
workload when they are aware of their scope of practice. According to Baranek(2013), it is
important for health professionals to work within their scope of practice
IMPACT OF WORKING OUTSIDE YOUR SCOPE OF PRACTICE.
It is detrimental to work outside their scope of practice since there is decreased
productivity and performance. The clients may experience time wastage leading to negative
attitude as one doesn’t serve them appropriately while they are performing activities outside
their scope. There are conflicts between coworkers as some feel they have a heavier workload
since they are left to do the majority of the tasks. Confusion and uncertainty may arise between
other departments as roles are mixed up. The agency faces legal repercussions if the clients sue
them for damages. According to Thompson(2010), it is important to stick to your scope of
practice for productivity.

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TOOLS TO USE TO STAY IN SCOPE OF PRACTICE
I plan to use the accrediting board’s guidelines to stay within my scope of practice. The
board that accredits hospital unit clerks in Canada has well-stipulated guidelines on the scope
of practice and the roles of a hospital unit clerk in the hospital. This will help me to complete
my task in transcribing medical orders since it has the various procedures and measures to be
used by hospital unit clerks in Canada.
I plan to use the policy and procedure manual in my place of work since different
hospitals have different protocols. The policy and procedure manual explains the different roles
of a hospital unit clerk according to a specific hospital. This assists me in my job description as it
ensures a complete outline of the workplace.
I plan to use my training and education as a basis to stay within my scope of practice.
This will help me since I will ensure I only do what I’m duly trained on.
CONCLUSION
The healthcare system is dependent on all professionals for its success and mainly
communication is by health records hence hospital unit clerks play an important role in
ensuring the smooth running of the operations.

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REFERENCES
Baranek, P. M. (2013). A review of scopes of practice of health professions in Canada: A
balancing act. Toronto: Health Council of Canada.
Mandl, K. D., Markwell, D., MacDonald, R., Szolovits, P., & Kohane, I. S. (2011). Public standards
and patients' control: how to keep electronic medical records accessible but
privateMedical information: access and privacyDoctrines for developing electronic
medical recordsDesirable characteristics of electronic medical recordsChallenges and
limitations for electronic medical recordsConclusionsCommentary: Open approaches to
electronic patient recordsCommentary: A patient's viewpoint. Bmj, 322(7281), 283-287.
Thompson, V.D (2010) Administrative and Clerical Procedures for Canadian health professional,
Pearson
Wang, S. J., Middleton, B., Prosser, L. A., Bardon, C. G., Spurr, C. D., Carchidi, P. J., ... &
Kuperman, G. J. (2011). A cost-benefit analysis of electronic medical records in primary
care. The American journal of medicine, 114(5), 397-403.

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