Reports to: Director of Nursing

Department:  Nursing

Job Functions:

Functions will primarily involve providing support to the Director of Nursing and Unit Managers to include monitoring the completion of records as well as nursing station organization.

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

Responsibilities:

Records Management Functions

Admissions:

• Initiate/coordinate admission process
• Complete admission checklist
• Conduct tours of 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 order 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 follows 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

Other duties as assigned