NUCL 152 Patient Chart Records introduces the learner to the forms used to create patient charts in the hospital. Information is given about how to create a patient admission chart, additional forms added to a chart to individualize it for a specific patient and the Nursing Unit Clerk's responsibilities for patient charts and chart forms. Actual forms are used for practice.
Prerequisites: Admission to the Nursing Unit Clerk program
Accessibility Services Notice
Students who would like an academic accommodation and who have a documented disability should contact Accessibility Services, if they have not already done so.Course Details| Total number of weeks | 8 |
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| Total Credits | |
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| Total Hours | 75 |
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Typical hours per week breakdown| Other | 75 |
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Learning Outcomes
Upon successful completion of this course, the learner will be able to:
- List the functions of the chart
- State charting rules and procedures
- State the function of the various forms within standard forms, surgical forms and supplemental forms
- Describe the NUC’s responsibilities for a pre-operative chart
- Describe the NUC’s responsibilities for a post-operative chart
- State the information the NUC transcribes to various forms within standard forms, surgical forms and supplemental forms
- Create a mock patient chart with the chart forms in the correct order
- Transcribe appropriate information to the various chart forms
- State the maintenance procedures required for charts
Teaching and Learning Approach
Online students create and follow their own study schedule. The instructor is available by phone during office
hours for one-on-one support. Emails can be sent at any time and will be answered during office hours.
Student will be expected to:
· complete graded items according to the due dates found in the online course calendar;
· participate in the online discussion forum with their classmates regarding how to individualize an admission
chart for a specific patient;
· create a mock chart for each assignment, following the information presented in the course;
· complete a mid-course exam based on the first half of the course; and
· complete a final exam based on all the information in the course, with emphasis on the second half.
Learning Resources
Required:
A 3-inch binder with 15 section dividers to file the chart forms from this course into; to act as a mock patient chart
binder.
The chart forms used for this course are uploaded as PDF files in the online course. These are to be printed and
filed into your Patient Chart Binder to create an example chart. Print and file the following:
· Standard Forms
· Surgical Forms
· Supplemental Forms
Recommended:
The textbooks for the MTED 100 and MTED 101 Medical Terminology courses are good resources for review of
your medical terminology:
· Language of Medicine
Detailed Course Content, Topics, and Sequence Covered
1. 1. Topic One: The Patient Chart Functions of the chart Charting rules and procedures
2. 2. Topic Two: Chart Forms Introduction to Chart Forms Chart Forms Types of Chart Forms Order of the Chart Part One: Standard Forms Introduction to Standard Forms Standard Chart Pack Forms Care Guide/Plan of Care Diversity of Standard Forms
3. 3. Topic Two: Chart Forms Part Two: Surgical Forms Introduction to Surgical Forms Pre-operative Responsibilities Post-operative Responsibilities Diversity of Surgical Forms
4. 4. Topic Two: Chart Forms Part Three: Supplemental Forms Introduction to Supplemental Forms Diversity of Supplemental Forms
5. 5. Topic Three: Chart Maintenance
6. 6. Complete Case Study Discussion: Individualizing a Chart
7. 7. Topic Three: Chart Maintenance
Assessment
| Title | Learning Outcomes | Value |
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| Welcome Discussion | | 1% |
| Assignment #1 | 7,8 | 25% |
| Midcourse Exam | 1.2.3.6 | 20% |
| Assignment #2 | 7.8 | 25% |
| Case Study Discussion | 3,4 | 4% |
| Final Exam | 1,2,3,4,5,6,9 | 25% |
| Total | 100% |
Grading Table
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Standard Nursing Unit Clerk, Medical Transcription, Editing and Documentation, and Pharmacy Technician Programs Grading Table
| Percentage |
Letter Grade |
GPA |
| 96 - 100 |
A+ |
4.33 |
| 92-95 |
A |
4.00 |
| 89-91 |
B+ |
3.33 |
| 86-88 |
B |
3.00 |
| 83-85 |
C+ |
2.33 |
| 80-82 |
C |
2.00 |
| 79 & lower |
F |
0.00 |
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See the Academic Calendar for General Information including how to withdraw from course(s) and other regulations.
Disclaimer
Information contained in this course outline is correct at the time of publication. Content of the course is revised on an ongoing basis to ensure relevance to changing educational, employment and market needs. The instructor will endeavor to provide notice of changes to students as soon as possible. The instructor reserves the right to add or delete material from courses.