Ward Clerk

Description

Ward Clerk/ Unit Clerk

PURPOSE: The primary purpose of your job position is to assist the Nurse Supervisor/Charge Nurse in their day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records, as may be required by the Director of Nursing, to ensure that our medical records are maintained in an informative and descriptive manner.

QUALIFICATIONS:

• Must possess, as a minimum, a high school education or its equivalent.
• On-the-job training will be provided.
• Basic knowledge of medical terminology and nursing practices is preferred.
• Must be willing to seek out new methods and principles and be willing to incorporate them into exiting nursing practices.

RESIDENT RIGHTS:

• Maintain the confidentiality of all resident care information including protected health information. Report known or suspected incidents of unauthorized disclosure of such information.
• Ensure that you treat all residents fairly, and with kindness, dignity, and respect
• Ensure that all nursing is provided in privacy
• Knock before entering the resident’s room
• Report all grievances and complaints made by the resident to the Nurse Supervisor/Licensed Practical Nurse
• Report all allegations of resident abuse and/or misappropriation of resident’s property immediately to the Nurse Supervisor
• Honor the resident’s refusal of treatments request. Report such requests to your supervisor
• Communicate respectfully and appropriately, respect culture differences among residents and staff

ESSENTIAL RESPONSIBILITIES AND DUTIES:

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures.
• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.
• Maintain an up-to-date roster of residents for your assigned unit.
• Fill out resident charge slips and submit to the Business Office.
• Answer telephone, page calls, deliver messages to residents, etc., as necessary.
• Maintain a current listing of emergency phone numbers for your assigned units.
• Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc., as required.
• Transcribe the physicians’ orders to care plans, medication cards, treatment plans, etc., as required.
• Report to the Nurse Supervisor/Charge Nurse discrepancies found in transcribing physicians’ orders, diet orders/changes, charting, etc.
• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, legibility, etc. as directed.
• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided as well as the resident’s response to the care.
• Record vital signs as directed.
• Follow new diet orders and/or diet changes to the Director of Food Services.
• Keeping nursing personnel informed of residents’ appointments.
• Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
• Admit, transfer, and discharge residents. Assist in arranging for transportation, packing resident’s belongings, escorting them to discharge/transfer area, loading, etc. as necessary.
• Complete necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
• Notify the Nurse Supervisor/Charge should a resident be discharged without a physician’s order.
• Complete necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
• Forward completed charts of discharged residents to the Medical Records/Health Information Department.
• Deliver mail, flowers, etc., to residents, as necessary.
• Direct visitors to resident rooms, office areas, etc., as necessary.
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Administrator.
• Assist in the orientation of newly assigned personnel as directed.
• Interpret department policies and procedures to personnel, residents, visitors, etc., as directed.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility.
• Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the unit and shift.
• Report known or suspected incidents of fraud to the Administrator.
• Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.
• Greet newly admitted residents upon admission. Escort to room, as necessary.
• Assist in escorting residents’ to/from activity and social functions.
• Encourage attending physicians to record and sign progress notes, physician’s orders, etc., on a timely basis and in accordance with current regulations.
• Assist in recordkeeping functions for nurse aide trainees.
• Report administrative problem areas to the Director. Assist in developing and implementing corrective action.
• Assist and necessary in orientation of newly assigned personnel to your unit.
• Attend in-service training programs as scheduled.

SAFETY AND SANITATION:

• Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies.
• Ensure that established departmental policies and procedures, including dress codes, are followed by your assigned nursing personnel.
• Ensure that the adequate supply of personal protective equipment is on hand and are readily available to personnel who performs procedures that involve exposure to blood or body fluids.
• Ensure that your unit’s resident care rooms, treatment areas, etc., are maintained in a clean, safe, and sanitary manner.
• Ensure that your assigned personnel follow established handwashing and hand hygiene technique in the administering of nursing care procedures.
• Ensure that all personnel wear and/or use safety equipment and supplies (i.e. back brace, mechanical lifts, proper lifting technique, etc.) when lifting or moving residents.
• Have the knowledge of what is in the MSDS binders, report missing/illegible labels and MSDSs to the safety officer or other designated person.

SPECIFIC REQUIREMENTS:

• Must be able to read, write, speak, and understand the English language
• Must be a supportive team member, contribute to and be an example of teamwork and the team concept
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public
• Must be able to follow written and oral instructions
• Must not pose a threat to the health or safety of their individuals in the workplace
• Must be able to move intermittently throughout the workday
• Must be able to function independently and have flexibility, personal integrity, and the ability to work effectively with other
• Must be willing to perform tasks that may involve exposure to the blood and/or body fluids
• Must be willing to assist in the evacuation of residents during emergency situations
• Must be able to push, pull, move, and/or lift a minimum of 25 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 50 feet.
• Must perform all additional tasks assigned to you by supervisor

QUALIFICATIONS:

• Must possess, as a minimum, a high school education or its equivalent.
• On-the-job training will be provided.
• Basic knowledge of medical terminology and nursing practices is preferred.
• Must be willing to seek out new methods and principles and be willing to incorporate them into exiting nursing practices.

Salary : $18 - $23