CNA Medical Clerk - PTI

Job Title:                    CNA/Medical Clerk

Job Code:                   CNA.MC

Department:              Inpatient

Division:                     Nursing

Salary Level:             Non-Exempt 4                                        

Reports To:                Inpatient Nurse Supervisor

Last Revised:             July 2021

Job description

Nursing Assistant (35%)

• Assists patients with daily living activities, ie, bathing, oral hygiene, changing bed linen, feeding, etc.
• Provide nourishment as indicated by physician order.
• Collects specimens (urine, stool, throat cultures and sputum)
• Completes finger stick glucose monitoring.
• Monitors intake and output.

Clerical (65%)

• Answering the telephone and directing calls to appropriate individual and/or answers routing questions concerning inpatient unit.
• Initiates the admission process by assembling the admission chart and preparing the chart for patient admission to the inpatient unit.
• Completes the admission process by transcribing physician orders to the appropriate record, requisitioning laboratory, radiology, or other tests, contacting ancillary medical services as ordered to schedule appointments or arrange patient consultation and arranges meals from dietary.
• Initiates final disposition of chart from inpatient to medical records department.
• Schedules follow up appointments, arranges laboratory, radiology, or other tests, and assures discharged patient has transportation. Transfers patient chart to pharmacy to finalize discharge medications.
• Maintains dietary changes, assures discharge patients have transportation. Transfers patient chart to pharmacy to finalize medications.

• Documents vital signs and other measurement data to the appropriated record. Maintains inpatient census information.
• Generates and files patient health summary on admission, maintains inpatient records such as filing laboratory and radiology reports: assures appropriate forms and number of forms, etc.

Job knowledge

• Knowledge and skill to perform basic clinical nursing care to acutely ill patients and assist in their daily living activities.
• Knowledge of proper handling and collection of specimens, preforming vital signs, and recognizing abnormal values.
• Basic knowledge of diseases and illnesses and the ability to recognize and report changes in the patient's condition to the registered.
• A practical knowledge of the medical facility's organization and services, the basic rules and regulations governing visitors and patient treatment, COBRA, and practical knowledge of standard procedures, medical records, and medical terminology.
• Knowledge of typing and computer use since both are used in performance of position duties.
• Knowledge of inpatient communication systems, transfers, referrals, and treatments.
• A good working knowledge of terms describing diseases, medical and surgical procedures, as well as standard abbreviations used by medical staff.
• Knowledge of requisitioning supplies and maintaining clerical supply levels.
• Knowledge of filing procedures and communication skills to relay medical information to members of the unit and other services of the hospital.
• Applicant must have a valid North Carolina driver's license.

Education/Experience

• High school graduate or GED, successfully completed an accredited program in nursing assistant, and had been certified as a Nursing Assistant. Preference given as applicants who have specialized training duties and CNA
• Six months experience in clerical duties, ie, typing, computer use, and filling. Experience can be documented through education or work experiences.
• Proficiency rated at 6 weeks.

Contacts with others

Personal contacts are with patient, families, and friends of patients, visitors to the hospital, physicians, nurses, and all hospital personnel. Contacts with patients are to provide nursing care. The clerk may assist the patient in obtaining hospital services available or assist in arranging transfers. There is also contact with other hospital departments regarding nursing services and treatment.

Confidential Data

The incumbent has access to confidential patient medical and personal information. The privacy act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administration, medical, and personnel records and all other pertinent both civil and criminal penalties for unlawful disclosure of records. Violation of such confidentiality shall be cause for adverse actions

Responsibility for Accuracy

The incumbent is responsible for accuracy of work performed. The charge nurse, supervising registered nurse, or immediate supervisor reviews work for accuracy and determines steps to prevent errors from reoccurring. Patient care provided by the incumbent contributes to completion of the prescribed plan of care and disposition of the patient. Incumbent initiates and follows through on all clerical procedures during the patient care and treatment process.

Completion of duties affects the attitude of patient and efficiency with which the hospital provides service and therefore could have negative effect on patient outcomes.

Incumbent performs nursing and clerical procedures pertinent to Inpatient. Uses judgement in determining priority of nursing care tasks based upon the diagnosis of the patient, their condition and special circumstances related to their needs. Assembles patient records according to prescribed format. Initiates appropriate requisitions from hospital staff. Records appropriate data into departmental log.

Mental/Visual/physical

Work in the various services within nursing services on in-patient requires walking, standing, bending, pushing and lifting in helping to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies

Resourcefulness and initiative

Incumbent works under the administrative supervision of supervisory Clinical nurse, GS-610-11, who administers control of the inpatient Department's functional duties. Receives technical directions from the Charge Nurse. Incumbent is responsible for

Initiating and following through on reoccurring clerical assignments. Work is primarily reviewed in terms of overall quality and efficiency of service provided to patients.

Guidelines consist of nursing and medical procedures on in-patient. Privacy Act guidelines, hospital policies and procedures, the incumbent uses judgement in locating and selecting the most appropriate guidelines, references and procedures for application in making minor deviations to adapt the guidelines to specific case. Unusual developments are referred to the supervisor.

Environment

Must be flexible in working hours. Work is performed in the hospital setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent is frequently exposed to communicable diseases. Incumbent is required to comply with Employee health program guidelines. Sometimes will be able to wear Personal protective equipment as required by hospital policy