Electronic Medical Records In Primary Care Essay

Discuss about the Electronic Medical Records in Primary Care.

Answer:

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.

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.

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.

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

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

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.

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.

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.

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.

How to cite this essay: