Professional documentation in health care

The written standards applied in the health care professional environments for documentation purposes of one`s activity.

professional documentation in health-care
professional documentation in the health care sector
professional written standards in health care
professional health care documentation

knowledge

sector-specific

Professional documentation in health care is an essential knowledge of the following occupations:

Doctors’ surgery assistant: Doctors’ surgery assistants support doctors of medicine in medical measures, in performing simple support activities during medical procedures, standardised diagnostic programmes and standardised point-of-care tests, ensuring surgery hygiene, cleaning, disinfecting, sterilising and maintaining medical devices and performing the organisational and administrative tasks required for operating a doctor`s surgery under supervision, following the orders of the doctor of medicine.
Medical records clerk:
Medical records clerks organise, keep up-to-date and archive patients` records for medical staff availability. They transfer medical information from a patient’s paper records to an electronic template.
Anaesthetic technician: Anaesthetic technicians assist specialised doctors in anaesthetics. They prepare operating theatres and other specialised clinics for anaesthetic procedures, prepare the equipment needed for anaesthesia, and assist with inducing and maintaining adequate anaesthesia and post-anaesthesia procedures. They do so under supervision, following the orders of the doctor of medicine.
Biomedical scientist: Biomedical scientists perform all laboratory methods required as part of medical examination, treatment and research activities, particularly clinical-chemical, haematological, immuno-haematological, histological, cytological, microbiological, parasitological, mycological, serological and radiological tests. They perform analytical sample testing and report the results to the medical staff for further diagnosis. Biomedical Scientists may apply these methods in particular in the infection, blood or cellular sciences.
Occupational therapist: Occupational therapists assist individuals or groups who have occupational limitations due to diseases, physical disorders, and temporary or permanent mental disabilities, in regaining their ability to perform daily activities. They provide treatment and rehabilitation to enable them to actively participate in society, to live their lives according to their wishes and to perform those activities that are meaningful to them.
Clinical coder: Clinical coders read patients’ medical records. They analyse and interpret medical statements about diseases, injuries and procedures. Clinical coders convert this information into health classification codes in order to calculate treatment reimbursements, to produce statistics and to monitor health care performance.
Dietetic technician: Dietetic technicians assist dietitians in planning nutritional programmes and in planning menus for patients as part of an overall treatment plan under supervision of a dietitian. Under supervision of a dietitian, dietetic technicians assist dietitians in patient reviews, enteral feeding discharge planning, and clinical auditing which includes nutritional screening.
Sterile services technician: Sterile services technicians ensure decontamination of medical devices in compliance with strict hygienic procedures. They dismantle and re-assemble sophisticated medical equipment through sterilising, cleaning, and repackaging it for further usage, under supervision, following the orders of the doctor of medicine or other qualified medical personnel.
Orthoptist: Orthoptists diagnose and treat anomalies of binocular vision. They examine, assess and treat vision impairments, squint, amblyopia and eye motility disorders. Orthoptists apply these methods in particular in the fields of paediatrics, neurology, neuro-ophthalmology, ophthalmology, orthoptics, optometry, pleoptics and strabology assessing functional diseases of the eye for improving functional disorders of the visual system. They also provide counselling, preventive measures and training activities and may refract and prescribe glasses, such as prism corrective glasses.
 
Speech and language therapist: Speech and language therapists focus on the aetiology, assessment, diagnosis, treatment, and prevention of communication and swallowing disorders in people of all ages in order to help them maintain, promote, improve, initiate, or recover the ability to communicate both verbally and nonverbally. They address the development of language, speech, vocal and hearing functions, and disorders and disabilities in the cranial, facial, and oral area.
Dietitian: Dietitians assess specific nutritional requirements of populations or individuals throughout their lives and translate this into advice which will maintain, reduce risk to, or restore people’s health. Using evidence-based approaches, dietitians work to empower individuals, families and groups to provide or select food which is nutritionally adequate, safe, tasty and sustainable. Beyond healthcare, dietitians improve the nutritional environment for all through governments, industry, academia and research.
Medical records manager: Medical records managers are responsible for managing activities of medical records units which maintain and secure patient data. They supervise, oversee and train employees while implementing medical department policies.
Cytology screener: Cytology screeners examine under a microscope samples of human cells obtained from various body parts such as the female reproductive tract, the lung or gastrointestinal tract, assist in identifying cell abnormality and disease such as cancer or infectious agents under supervision, following the orders of the doctor of medicine.The abnormal cells are being transferred to the pathologist for medical diagnosis. They may also work under the supervision of a biomedical scientist. They do not treat patients or assist in medical treatments.

Professional documentation in health care is optional for these occupations. This means knowing this knowledge may be an asset for career advancement if you are in one of these occupations.

Medical administrative assistant: Medical administrative assistants work very closely with health professionals. They provide office support such as correspondence, fixing appointments and answering queries of patients.
Pharmacologist: Pharmacologists study the manner in which drugs and medicaments interact with organisms, living systems, and their parts (i.e. cells, tissues, or organs). Their research aims at identifying substances that can be ingested by humans and that exert adequate biochemical functions for curing illnesses.
Physiologist: Physiologists study and exert research on the functioning of different living organisms, the parts they are composed of, and their interactions. They understand the fashion in which living systems react to factors such as diseases, physical activity, and stress, and use that information to develop methods and solutions to even out the effect that those stimuli have in living bodies.
Front line medical receptionist: Front line medical receptionists greet clients and patients as they arrive at the medical facility and check them in, collect patient notes and make appointments work under the supervision and direction of healthcare institution manager.
Medical transcriptionist: Medical transcriptionists interpret dictated information from the doctor or other healthcare professionals and convert it into documents. They create, format and edit medical records for patients based on the provided data and take care to apply punctuation and grammar rules.
Geneticist: Geneticists study and focus their research on genetics. They analyse the fashion in which genes interact, operate, and inherit traits and characteristics. Based on their research, they attend patients with inherited diseases and conditions, congenital malformations, and genetic matters at large.
Chiropractic assistant: Chiropractic assistants perform routine and administrative tasks to support patient care and work under the sole direction and supervision of a Chiropractor or Specialized Chiropractor. They may interview patients, keep records of the case history, assist Chiropractors or Specialized Chiropractors in providing patients examination and perform administrative tasks. Chiropractic assistants work within defined contexts using agreed protocols and procedures.
Emergency medical dispatcher: Emergency medical dispatchers respond to urgent calls made to the control center, take information about the emergency situation, the address and other details and dispatch the nearest ambulance or paramedic helicopter.
Epidemiologist: Epidemiologists centre their research on origin and causes for illness eruption in humans. They determine the way in which diseases are spread out and propose risk preventive measures to health policy organisms.

References

1. Professional documentation in health care – ESCO