Administrative Skills, Clinical Information, Communication Skills, Customer Support/Service, Director of Nursing (DON), Emergency Planning, Health Information Management, Healthcare, Information/Data Security (InfoSec), Medications, Nursing, Nursing Management, Physician Verbal/Telephone Orders, Presentation/Verbal Skills, Privacy Controls, Process Management, Records Management, Systems Maintenance, Telephone Skills, Writing Skills
JOB DESCRIPTION
Unit-Ward Clerk
Department: Nursing
FLSA Classification: Non-exempt
Reports to: Director of Nursing
Overview of the position:
The Unit-Ward Clerk role involves supporting the Director of Nursing and Unit Managers by monitoring thecompletion of records as well as nursing station organization.
Responsibilities:
Records Management Functions
Admissions:
- Initiate/coordinate admission process.
- Complete admission checklist.
- Conduct tours of the facility with prospective admissions.
During the Resident stay: - Thin in-house records in accordance with the written policy and procedure and files in discharge chart order for the in-house overflow file.
- Maintain in-house chart appearance and organization.
- Maintain a monitoring system to assure telephone orders and other information are signed and returned by the physician or other professionals.
- File all incoming clinical information in the in-house records on a daily basis.
- Check telephone orders daily for transcription on physician's orders, medications and treatment records, care plants, etc.
- Monitor timeliness of physician's visits on a monthly basis in conjunction with the manager of health information services.
- Prepare paperwork for transfer or referrals.
- Photocopy documents.
- Act as a liaison between Nursing and other departments.
- Protect the privacy and security of health information and follow confidentiality and release of information procedures.
- Audits of resident's records as requested.
- Follow the safety guidelines and regulations set forth by the facility.
- Follows emergency action plan.
Discharge: - Prepare paperwork for discharge
- Assemble record from the nursing station and the overflow files in established discharge order
- Performs additional duties and assignments, as requested
Qualifications for the position: - Minimum Entry Level
- General office skills including filing, organizing, and tracking
- Oral and written communication skills
- Good customer service and telephone skills/etiquette. Tact and warmth when dealing with family and residents
- Ability to work within a team
- Empathy for the elderly
- Ability to work systematically and without continuous supervision