Medical Record Transcribing Program Handbook A Health Science Program

Transcription

1 Medical Record Transcribing Program Handbook A Health Science Program 1

2

3 Table of Contents Medical Record Transcribing... 1 Program Handbook... 1 Welcome to the Medical Record Transcribing Program... 4 Program Approvals/Certifications... 4 Program Requirements... 4 Required Text... 4 Bookstore... 4 Program Structure... 5 Program Content... 5 Grading Policy... 7 Student Progress Cards and Reports:... 7 Grading and Work Ethic Scale... 7 Work Ethic Scale Examples... 8 General Policies... 9 Attendance, Tardies, and Absences - Unexcused Absence Policy and Make-up Requirements:... 9 Fire Drills/Disaster Drills:... 9 Smoking:... 9 Telephone Usage - Cell Phone Use... 9 Equipment, Supplies, Furniture - Computer use... 9 Instructor Access:... 9 Confidentiality:... 9 Grievance Procedure (OCPS CTE Student Handbook):... 9 Uniform/Dress Code Student ID s: Responsible Conduct: Cheating/Plagiarism: Student Insurance: Alcohol/Drugs: Forms Requiring Student Signatures

4 Welcome to the Medical Record Transcribing Program Welcome to the Medical Record Transcribing Program. We are proud to know that you have chosen Orange County Public Schools as a stepping-stone to your career. This is an important phase in your life and we hope to make it meaningful and productive for your future. This handbook has been designed to guide you throughout your chosen program. During the general campus orientation, you were provided a District Student Handbook and a District Code of Conduct as well. You will find requirements, policies, and expectations for successful completion of your chosen program. We advise you to become familiar with the guidelines, requirements, and policies. It is your responsibility to understand these if you are to optimize your educational experience. If you have questions about the handbook, or if you feel a particular concern is not addressed, do visit with your instructor. We all wish you a very successful academic experience. Program Approvals/Certifications Winter Park Tech Council on Occupational Education Association for Healthcare Documentation Integrity (AHDI) Program Requirements TABE scores: Mathematics 9; Language 11; Reading 11 Meet with Guidance Counselor and financial aid advisor (if applicable) Complete application process Required Text Your instructor will provide you with a Syllabus that will include the textbook requirements. Bookstore The bookstore at each tech center stocks textbooks required by the programs, plus a limited selection of school supplies. T-shirts, hats, mugs and other items with the school logo may also be available. Books are only sold to campus students unless otherwise authorized by the school Director or designee. The campus maintains a schedule of both day and evening hours of operation. Financial aid students on a book deferment must bring back ALL books unopened and materials unused to cancel their deferment within the first five days of school. Any books or materials used will be the responsibility of the student and will have an outstanding fee until paid in full. Refunds or exchanges for books may be processed under the following specific circumstances: A receipt must be provided by the customer. The book must be new (no markings, no broken binding, no imprints on the cover). All requests for book refunds must occur within 30 days of purchase. 4

5 Program Structure This program is a planned sequence of instruction consisting of two occupational completion points. When offered at the postsecondary adult career and technical level, this program is comprised of courses which have been assigned course numbers in the SCNS (Statewide Course Numbering System) in accordance with Section (1), F.S. Career and Technical credit shall be awarded to the student on a transcript in accordance with Section (3)(b), F.S. OCP Course Number Course Title A B HIM0009 Introduction to Health Information Technology Course Length HIM0074 Medical Transcriber hours HIM0075 Medical Transcriber hours HIM0081 Medical Transcriber hours SOC Code 90 hours Program Content This program offers a sequence of courses that provides coherent and rigorous content aligned with challenging academic standards and relevant technical knowledge and skills needed to prepare for further education and careers in the Health Science career cluster; provides technical skill proficiency, and includes competency-based applied learning that contributes to the academic knowledge, higher-order reasoning and problem-solving skills, work attitudes, general employability skills, technical skills, and occupation-specific skills, and knowledge of all aspects of the Health Science career cluster. After successfully completing this program, the student will be able to perform the following: 01. Demonstrate language arts knowledge and skills 02. Demonstrate mathematics knowledge and skills. 03. Demonstrate science knowledge and skills 04. Demonstrate an understanding of the healthcare delivery system and health occupations. 05. Demonstrate the ability to communicate and use interpersonal skills effectively. 06. Explore health informatics and information management as a profession. 07. Demonstrate an understanding of health data concepts. 08. Describe the functions of a health record. 09. Demonstrate a basic understanding of Health Information Technology. 10. Discuss classification systems, clinical vocabularies and terminologies. 11. Explore ethical issues in health informatics and information management 5 5

6 12. Identify the importance of privacy and health records law in healthcare. 13. Demonstrate computer knowledge and skills. 14. Demonstrate personal money-management concepts, procedures, and strategies. 15. Demonstrate employability skills. 16. Demonstrate leadership and teamwork skills needed to accomplish team goals and objectives. 17. Solve problems using critical thinking skills, creativity and innovation. 18. Demonstrate the importance of health, safety, and environmental management systems in organizations and their importance to organizational performance and regulatory compliance. 19. Describe the roles within teams, work units, departments, organizations, interorganizational systems, and the larger environment. 20. Use appropriate medical and scientific terminology. 21. Apply rules of English grammar and punctuation. 22. Utilize medical references. 23. Apply medical transcription technology. 24. Practice safety and security specific to medical transcriber. 25. Explain the role of health information services. 26. Demonstrate ethical and legal principles with regard to the use of medical records. Program must be taught in accordance with the guidelines of the model curriculum of the: Association for Healthcare Documentation Integrity (AHDI) Kiernan Avenue Suite 130 Modesto, CA Phone: Toll Free (800) Direct (209) Fax: Web site: ahdi@ahdionline.org Students should be encouraged to become members of their professional organization, and participate in the state/local chapter activities. Admissions should be limited to individuals who have the ability to keyboard at a speed of 45 correct words per minute. The program should prepare the graduate to take the national examination to become a Registered Medical Transcriptionist. Certification is voluntary and is sponsored by the Association for Healthcare Documentation Integrity (AHDI). The Medical Record Transcribing program is an online program. Students must have access to a PC. Macintosh computers are not compatible with the system. All students must have access to a Microsoft Word version Students will receive a syllabus of all components of the program at orientation. Students are expected to log on daily and participate in the assignments. All assignments are to be submitted as a word processing document. Directions for using the DropBox feature will be provided at orientation. 6

7 Grading Policy Student Progress Cards and Reports: At the end of each marking period (9 weeks), the instructor will complete a report card. This represents an overview of the student s growth. It emphasizes course/program achievements as well as student attendance, work ethic and skills. Intervention for a student making unsatisfactory progress will be initiated at the midpoint of each nine weeks by the instructor to ensure appropriate student progress and achievement. Students study under a competency-based system and are graded as competency requirements are satisfactorily completed. The following Orange County Public Schools approved grading scale is used to report student achievement. The formula to determine each student s grade is calculated each grading period using this calculation 65% of the grade is coursework in the career certificate program and 35% of the grade is based on the professional work ethic. The grading policy will be covered in more detail during the campus orientation. Grading and Work Ethic Scale Grade Percentage Work Ethic Definition A Outstanding progress B Above Average Progress C Average Progress D Lowest Acceptable Progress F Below 60 0 Failure 7 7

8 Work Ethic Scale Examples Trait Attendance Personal Characteristics Teamwork Appearance Attitude Productivity Organization Communication Cooperation Respect Sample of Appropriate Behavior Attends class, arrives/leaves on time; notifies instructor in advance of a planned absence. Displays loyalty, honesty, trustworthiness, dependability, reliability, initiative, self-discipline, and self-responsibility. Respects the rights of others, respects confidentiality; is a team worker; is cooperative; is assertive; displays a customer service attitude; seeks opportunities for continuous learning; demonstrates mannerly behavior. Displays appropriate dress, grooming, hygiene, and etiquette. Demonstrates a positive attitude; appears self-confident; has realistic expectations of self. Follow safety practices; conserves materials; keeps work area neat and clean; follows directions and procedures; completes assignments on time, makes up assignments punctually; participates. Displays skills in prioritizing and management of time and stress; demonstrates flexibility in handling change. Displays appropriate nonverbal (eye contact, body language) and oral (listening, telephone etiquette, grammar) skills. Displays leadership skills; appropriately handles criticism, conflicts, and complaints; demonstrates problem-solving capability; maintains appropriate relationships with supervisors and peers; follows chain of command. Deals appropriately with cultural/racial diversity; does not engage in harassment of any kind. 8

9 General Policies Attendance, Tardies, and Absences - Unexcused Absence Policy and Make-up Requirements: The OCPS Career & Technical Education Student Handbook policy will be upheld in the Medical Record Transcribing program. (See OCPS CTE Student Handbook.) Fire Drills/Disaster Drills: Regulations require that fire drills, bad weather drills, and lockdown procedures be held periodically throughout the school year. Each drill has specific procedures and warnings that will be taught to your class by the instructor. Please take note of the following guidelines: Every drill is to be taken seriously. A drill can take place at any time. All students should follow the exact procedures for each drill. Students should follow the lead of their teacher so that they will be in compliance with the drill and know the routine in case of an actual event. To turn in a false alarm is a criminal offense. Smoking: Smoking is not allowed on any campus per regulations of Orange County Public Schools. Telephone Usage - Cell Phone Use: Cell phones need to be in the silent mode. Emergency calls can be sent to the Campus Main number. Students may only use the cell phones during designated breaks or at lunch. Students are required to ask any clients receiving treatments to turn off their cell phones. Equipment, Supplies, Furniture - Computer use: Computers are the property of OCPS and students must respect the district s policies outlined in the student handbook. They are not for personal use. No s, blogging, or personal surfing. Printers are for school work only. Be frugal when using paper and ink. Remove personal items from computer desks when not in use. No food or drink around the computer desks. Headsets are permitted. Digital music devices are encouraged during independent study periods only. Instructor Access: Monday through Friday 8AM to 2PM. Faculty are always available by . We will return all messages within 24 hours during the week and 48 hours on the weekend. Confidentiality: Federal legislation (HIPAA) protects the confidentiality of medical information and patient rights. Medical Record Transcribers must follow the HIPAA requirements. Students should not discuss Patient information with family members or others. Gossip about patients, facilities, and costudents is considered a breach of confidentiality and the student can be withdrawn from the program. Grievance Procedure (OCPS CTE Student Handbook): A student is encouraged to resolve an issue at the classroom level. If there is no resolution at the classroom level, the student may present the concern to the counselor. If a satisfactory solution is not reached, then the issue is regarded as a grievance. Steps to be followed regarding a student grievance are the following: 1. The student must state the grievance in written form to the appropriate school administrator. 2. Within five school days, the appropriate administrator will meet with the student. The student will be afforded the opportunity to state his/her view and to present evidence of witnesses. A decision will be made. 9 9

10 3. Within five school days of the initial meeting a student may appeal the outcome of that meeting to the technical center senior director who will schedule a meeting with the student within two weeks. A decision will be made. 4. If the student is not satisfied with the decision, he/she may further appeal to the associate superintendent or designee who will convene an impartial board to review the grievance and render a final decision. 5. If the grievance is not settled to the student s satisfaction at the local level the student may contact: The Council on Occupational Education, 7840 Roswell Road, Suite 325, Atlanta, GA Telephone number: Uniform/Dress Code. Because this program is provided online, there is no standard dress code. If the student is on campus, however, professional dress is expected. Student ID s: Students must wear ID s at all times when on campus. Responsible Conduct: Students are expected to conduct themselves in an acceptable manner and reflect the individual goals and the purpose of Orange County Public Schools. The Center Director has the responsibility to immediately notify the appropriate law enforcement agency when any student under his or her jurisdiction violates the law. The Orange County School Board Code of Student Conduct will be enforced. All Medical Record Transcriber students will receive a copy during orientation Cheating/Plagiarism: Cheating or plagiarism on any classroom or clinical work assigned is considered a serious offense. Plagiarism is the act of copying someone else s work and presenting it as your own. This would include copying directly from textbooks, other references, an Internet Site, or other students work. It is a form of cheating and will result in the same consequences as cheating. All incidents of cheating and/or plagiarism will result in a zero for that assignment and a written anecdotal in the student s record. A second offense results in automatic dismissal from the program. Student Insurance: All technical students must purchase school accident insurance or provide proof of insurance that covers them while in school-related activities. For a nominal fee a student may purchase 24-hour coverage. Insurance requirements must be taken care of upon registering for the program. Alcohol/Drugs: The Orange County Public School Drug-Free School Act is covered in the OCPS CTE Student Handbook. (See OCPS CTE Student Handbook.) 10

11 Forms Requiring Student Signatures Print Student Name Student Number I, the undersigned, have read and understand the following sections as written in the Medical Record Transcribing Handbook and do agree to abide by the policies as written: (initial each section below) Policies/Requirements Attendance Policy Agreement Dress Code Requirement Grading Policy Student Signature Date Witness Signature (if required) Date

12

13

14 14 Medical Record Transcribing Program Handbook