Job Description
Medical Records/Unit Clerk
Monday thru Friday, No holidays or weekends
Assume responsibility for clerical/secretarial tasks on specified units. Must function independently and have flexibility, personal integrity and the ability to work effectively with residents, personnel and support agencies. Must be computer literate, able to work in a Windows environment. Must be able to communicate with the medical staff, nursing personnel and other department supervisors.
Assist the Medical record designee with audit duties, filing and with computer data entry.
ESSENTIAL REQUIREMENTS, DUTIES, AND RESPONSIBILITIES
1. Maintain confidentiality at all times with regards to medical records and resident information.
2. Protect all medical record information from loss, defacing or destruction before retention period ends.
3. Process admission and discharge records timely and accurately.
4. Assemble admission packets.
5. Complete all information on admission records and place in medical record holder following facility policy and procedure.
6. File medical records promptly and accurately.
7. Retrieve medical records promptly upon request by authorized individuals.
8. Provide each resident with appropriate name bands.
9. Check charts for completion of history and physicals.
10. Identify incomplete or inaccurate documentation and report to Unit Manager to notify the individuals responsible for completion.
11. Handle overflow from in-house records, audits and file in discharge record order.
12. Complete death charts per policy and forward to Medical Records in a timely manner.
13. Complete OTD schedule for physicians, according to regulatory guidelines and facility policy.
14. Work closely with the unit charge nurse/Unit Manager. Execute any clerical duties as requested.
15. Record items on charts at the direction of the charge nurse, i.e. daily/weekly vital signs.
16. Chart monthly vital signs, weights, consults and labs on flow sheets as needed.
17. Place lab and diagnostic reports on charts after seen and initialed by physician.
18. Add necessary sheets to charts, check for correct order and purge as needed.
19. Complete weekly and monthly lab requests.
20. Audit medical records, as assigned.
21. Receive and file all diagnostic reports promptly and accurately.
22. Schedule appointments for diagnostic tests to be performed on residents as ordered. Audit transfer/discharge information for accuracy and completeness.
23. Prepare time and work schedules for unit.
24. Serve as a receptionist for unit, utilize proper telephone etiquette, answer telephone promptly, and communicate messages accurately.
25. Fill in for receptionist at main desk or Nursing Service Office Assistant when needed.
26. Keep counter tops, drawers, and cupboards in order.
27. Attend continuing educational programs, meetings and in-services as assigned.
28. Comply with department and facility procedures, fire prevention and safety standards.
29. Employment is contingent on successful completion of the pre-employment and criminal background check.
30. Is subject to exposure to infectious waste, diseases, conditions, etc, including the AIDS and Hepatitis B viruses.
31. Follow Residents’ rights policies at all times.
32. Come to work as scheduled and consistently demonstrate dependability and punctuality.
33. Consistently work cooperatively with all staff and accept assigned duties in a cooperative manner.
Other reasonable duties as assigned by supervisor and/or Additional duties that are required, although may be assigned to another employee due to special circumstances applicable to the employee. Employment is contingent on successful completion of the pre-employment requirements and criminal background check.
ESSENTIAL PHYSICAL AND MENTAL JOB REQUIREMENTS
Must be proficient in reading and writing and understand the spoken and written word. Must be able to apply good sound nursing judgement while applying the Nurse Practice Act. Must have some computer skills. Must be able to hear with corrective or adaptive devices and see adequately with corrective eyewear. Must have simple computational skills such as addition, subtractions, multiplication, division and percentages. Must be able to stand for long periods of time, bend at knees and waist, push and pull, turn and lift a minimum of 50lbs.
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