NAHUC Exam Detailed Content Outline Released 12/2011

I. TRANSCRIPTION OF ORDERS 30%

A. Processing

1. Check charts for orders that need to be transcribed

2. Interpret medical symbols, abbreviations, and terminology

3. Clarify orders as needed

4. Prioritize orders and tasks

5. Process orders according to priority (i.e., standing, one-time, prn, and stat)

6. Enter orders on a paper (Kardex) or computerized patient treatment plan

7. Process pathway protocols

8. Schedule diagnostic tests and procedures

9. Initiate test preparation procedures

10. Process orders for diagnostic and therapeutic tests and procedures

11. Process nursing treatment orders

12. Process pre- and post-operative charts

13. Process medication orders (e.g., scan, FAX, tube)

14. Process orders for parenteral fluids

15. Recognize order categories (e.g., medication, diagnostics)

B. Notification

1. Notify staff of new orders

2. Notify and document consulting physicians of consult requests

3. Indicate on the order sheet that each order has been processed

4. Sign off orders (e.g., signature, title, date, and time)

C. Requests

1. Request services from ancillary and support departments

2. Facilitate requests for special equipment (e.g., bariatric equipment, supplies)

3. Request supplies and equipment

4. Request patient information from external facilities

II. COORDINATION OF HEALTH UNIT 45%

A. Admission

1. Assemble patient charts (hard copy or electronic) upon admission

2. Obtain patient information prior to admission

3. Initiate patient admission

4. Notify nursing staff and physicians of patient admissions, transfers, discharges, and returning surgical patients

B. Patient Results Processing

1. Receive diagnostic test results

2. Notify nursing staff of diagnostic test results

3. File diagnostic test results

C. Discharges/Transfers

1. Assemble necessary forms (hard copy or electronic and perform clerical tasks for patients being transferred to an external facility

2. Prepare patient charts and perform clerical tasks for discharge or transfer to other units within the healthcare facility

3. Initiate protocol and follow policies for expired patients

4. Notify departments and individuals when patients are discharged (e.g., home, expired, AMA, transferred, etc.)

5. Disassemble patient charts, put in designated order, and send to medical records office upon expiration or discharge

6. Select disposition of discharged patient

D. Unit Responsibilities/Clerical

1. Maintain a supply of chart forms

2. Maintain stock of unit materials (e.g., patient care supplies and equipment, clerical and desk supplies)

3. Maintain patient charts by thinning and adding forms as needed

4. File forms and reports

5. Arrange for maintenance and repair of equipment

E. Reports and Record Keeping

1. Report unit activities to on-coming shift

2. Coordinate entry of ADT patient information into all required data management systems (e.g. census logs, boards)

3. Chart information onto designated forms (hard copy or electronic)

4. Maintain patient assignment board

5. Perform quality assurance on charts (i.e., verify that chart forms are filed and labeled correctly, all orders have been transcribed, allergies are noted, etc.)

F. Personnel Management

1. Orient new staff members to the unit

2. Precept new or student unit coordinators

3. Communicate facility policies to visitors, patients and staff (i.e., visiting hours, no smoking, etc.)

4. Greet patients, physicians, visitors, and facility staff arrive on the unit

5. Respond to patient, physician, visitor, and facility staff requests and complaints

G. Safety and Security

1. Maintain a hazard-free work environment

2. Maintain unit security

3. Participate in emergency and disaster plans

4. Respond to cardiac or respiratory arrests

5. Initiate call to cardiac or respiratory arrests

6. Comply with regulatory agency guidelines/rules

7. Identify and correct potential hazards

8. Adhere to Universal Blood and Body Fluid Precautions

9. Adhere to infection control standards

H. Confidentiality and Patient Rights

1. Screen telephone calls and visitor requests for patient information

2. Restrict access to patient information (i.e., charts, computer, and cell phones)

3. Adhere to Patient’s Bill of Rights

4. Refer ethical concerns to designated resources

5. Acts as patient advocate

III. EQUIPMENT/TECHNICAL PROCEDURES 10%

A. Communication

1. Communicate with patients and staff via intercom

2. Send and receive documents via fax machine, scanners, emails, etc.

3. Contact personnel via telecommunications systems (i.e., pagers, cell phones)

4. Answer and process unit telephone calls

B. Computers and Peripherals (printers, scanners, etc.)

1. Maintain computer census (i.e., ADT functions)

2. Follow computer down-time procedures

3. Use software for word processing, emailing, spreadsheets, etc.

4. Generate reports

5. Troubleshoot problems

C. Miscellaneous Equipment

1. Duplicate documents using a copy machine

2. Transport patient specimens, supplies, and medication using pneumatic tubes

IV. PROFESSIONAL DEVELOPMENT 15%

A. Training

1. Attend in-service training sessions

2. Attend department, staff or health unit coordinator meetings

3. Participate in interdisciplinary committees and councils

B. Individual Development

1. Review facility specific publications, memos, policies

2. Pursue and maintain certification

3. Participate in performance improvement activities

4. Participate in cross-training activities

C. Critical Thinking

1. Use conflict resolution techniques

2. Demonstrate customer service skills

3. Respect patient/family cultural/religious beliefs