Details:

Fee: $82.50 Supply Fee.

Outcomes:

After completing this class, students should be able to:

• Explain the purpose of the patient’s chart including its importance as a legal document
• Demonstrate the process of preparing and maintaining patients’ charts
• Explain the importance of confidentiality related to the patient’s chart
• Demonstrate the five guidelines for filing records on a patient’s chart
• Analyze and demonstrate the steps for the transcription of doctors’ orders
• Demonstrate how to transcribe medication, therapy, activity, positioning, observation, diagnostic, laboratory, and miscellaneous orders
• Distinguish between doctors’ orders for tests, therapies/services, medication, and nursing orders and analyze the health unit coordinator’s responsibilities for transcription
• Explain the need to prioritize urgent and non-urgent orders
• Demonstrate how to admit , discharge, and transfer a patient
• Demonstrate the purpose and use of symbols during the transcription process
• Identify and state the purpose of standard and supplemental chart forms
• Explain the health unit coordinator’s responsibilities in emergencies, such as fire or disaster situation
• Demonstrate the health unit coordinator’s patient-centered activities, including the steps for completing admission, discharge, transfer, and surgical-related forms
• Using practice software demonstrate the process of retrieving diagnostic test results using the computer
• Analyze when it is appropriate to make corrections on a patient’s medical chart