Ward Clerk Part Time

JOB SUMMARY:

The primary purpose of the Ward Clerk position is to assist the Charge Nurses in their day-to-day recording and charting of medical and/or administrative information.

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures.
• Maintain the Daily Census Report and submit to 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 unit.
• Maintain and forward daily tardy and absentee reports to Business Office.
• Record appropriate resident identification data on designated medical records, wristbands, , etc. as required.
• Transcribe physicians’ orders to care plans, medication cards, treatment plans, etc., as required.
• Report to the 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 physicians’ order, legibility, etc, as directed.
• Chart nurses’ notes in an informative and descriptive manner.
• Record vital signs as directed.
• Forward new diet orders and/or diet changes to the Food Service Manager.
• Keep nursing service personnel informed of residents’ appointments.
• Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
• Notify the resident’s next-of-kin when there is a change in the resident’s condition.
• Notify, as instructed, the resident’s, the resident’s next-of-kin when the resident is involved in an accident or incident.
• Fill out and complete accident and incident reports as directed.
• Admit, transfer, and discharge residents. Assist in arranging for transportation, packing residents’ 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 Charge Nurse should a resident be discharged without a physician’s order.
• Forward completed charts of discharged residents to the Medial Records Department.
• Pick up mail from box in a.m. and file.
• File items in baskets daily.
• Take telephone orders to Medical Records daily.
• Take charts to Medical Records after death or discharge once physician signs orders.
• Go through charts daily to check for loose papers.
• Purge all charts on a quarterly basis.
• Keep records of telephone orders when going out and returned.
• Day after admission put face sheets on charts.
• Direct visitors to resident rooms, office areas as necessary.

• Attend various committee meetings of the facility as assigned.
• Assist in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee as directed.
• Provide data to the Quality Assurance & Assessment Committee as requested.
• Participate in developing the agenda for the Care Plan Committee meetings as necessary.
• Implement recommendations from established committees as instructed.

• 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 department 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.

• 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.
• Report administrative problem areas to the Charge Nurse. Assist in developing and implementing corrective action.
• Inform family members as necessary of the death of a resident as directed.
• Call funeral homes when requested by family…