Ward Clerk

Overview

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

• Record medical and administrative information in accordance with established charting and documentation policies and procedures.
• Maintain the Daily Census Report and submit it to the Nurse Supervisor/Charge Nurse.
• Maintain an up-to-date roster of residents for the assigned unit.
• Fill out resident charge slips and submit to the Business Office.
• Answer telephone calls, page messages, deliver messages to residents, etc., as necessary.
• Maintain a current listing of emergency phone numbers for the assigned unit.
• Maintain and forward daily tardy and absentee reports to the Business Office.
• Transcribe physicians  orders to care plans, medication cards, treatment plans, etc., as required.
• Report discrepancies found in transcribing physicians  orders, diet orders/changes, charting, etc., to the Nurse Supervisor/Charge Nurse.
• Review medication cards for completeness, accuracy in transcription of the physician s orders, legibility, etc., as directed.
• Chart nurses  notes in an informative and descriptive manner that reflects the care provided and the resident s response to the care.
• Forward new diet orders and/or diet changes to the Director of Food Services.
• Notify the resident s next-of-kin when there is a change in the resident s condition as instructed.
• Admit, transfer, and discharge residents. Assist in arranging transportation, packing residents  belongings, escorting them to discharge/transfer area, loading, etc., as necessary.
• Complete necessary medical and administrative records upon admission, transfer, and/or discharge.
• Forward completed charts of discharged residents to the Medical Records/Health Information Department.
• Attend various facility committee meetings as required (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment).
• Assist the Nurse Supervisor/Charge Nurse in developing work assignments, schedules, etc., as required.
• Develop and maintain a good working rapport with inter-departmental personnel and other departments within the facility.
• Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.
• Greet newly admitted residents upon admission and escort to room as necessary.
• Encourage attending physicians to record and sign progress notes and physicians  orders in a timely manner and in accordance with current regulations.
• Inform family members of a resident s death as instructed.
• Call funeral homes when requested by the family.
• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control).
• Participate in appropriate in-service training before performing tasks involving potential exposure to blood/body fluids.
• Participate in the implementation and maintenance of the infection control program for monitoring communicable and/or infectious diseases, including TB, among residents and personnel.
• Inform the Nurse Supervisor/Charge Nurse of equipment and supply needs.
• Ensure all personnel involved in providing care to residents are aware of the resident s care plan and refer to it prior to administering daily care.
• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
• Treat all residents fairly, with kindness, dignity, and respect.
• Assist in recording all incidents/accidents and file according to established policies and procedures.
• Agree not to disclose resident s protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Other duties as assigned by the supervisor/DON/Administrator.

This position has no supervisor responsibilities.

Education and/or Experience

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