Physical Therapist - Trinity Campus

Northeast Montana Health ServicesFaith Lutheran Home 1000 6th Avenue North Wolf Point, MT 59201 Phone: View phone number on click.appcast.io Department: Nursing Reports To: Director of Nursing / Assistant Director of Nursing / Administrator Employment Status: Non-Exempt Facility: Faith Lutheran Home

POSITION SUMMARY

The Ward Clerk provides clerical, organizational, and administrative support to the nursing department to promote efficient operation of the nursing units and continuity of resident care. The Ward Clerk works closely with nursing staff, residents, families, providers, pharmacies, outside healthcare organizations, and other facility departments. The Ward Clerk does not independently perform nursing assessments, make clinical decisions, or provide nursing services outside the employee's education, training, certification, or licensure.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Nursing Unit Support Provide clerical and administrative support to the Director of Nursing, Assistant Director of Nursing, charge nurses, and nursing staff. Answer nursing unit telephone calls and appropriately route calls and messages. Assist with maintaining an organized nurses' station and nursing department work areas. Receive, organize, and distribute nursing-related correspondence, forms, reports, and other documents. Assist nursing staff with locating forms, records, policies, and other information needed for resident care. Maintain confidentiality of resident, employee, and facility information. Medical Records and Documentation Support Assist with organizing and maintaining resident medical records in accordance with facility policy. File or scan documents into the appropriate resident record as assigned. Assist with ensuring laboratory results, consultation reports, hospital records, provider documentation, and other clinical documents are appropriately routed to nursing staff. Identify missing documents and notify the appropriate nursing staff. Assist with preparing records for appointments, transfers, hospitalizations, discharges, audits, and other authorized purposes. Assist with maintaining nursing forms and ensuring current forms are available to staff. Follow HIPAA requirements and facility policies regarding confidentiality and release of information. Physician and Provider Support Assist with preparing paperwork and records for provider rounds. Maintain provider communication forms and other documentation as directed by nursing staff. Route provider orders, recommendations, reports, and communications to the licensed nurse responsible for review and follow-up. Assist with scheduling or coordinating resident appointments as assigned. Communicate appointment information to nursing staff and other appropriate departments. Assist with obtaining requested medical records from hospitals, clinics, laboratories, and other healthcare providers. Orders and Communication Receive incoming documents, faxes, and electronic communications and promptly route them to the appropriate licensed nurse or department. Assist with processing clerical portions of physician/provider orders as directed by. The Ward Clerk shall not independently interpret, accept, transcribe, clarify, modify, or implement medical orders unless specifically authorized by law, facility policy, and the employee's applicable professional license. Promptly notify licensed nursing staff of communications requiring clinical review or action. Resident Appointments and Transportation Coordination Assist with maintaining the resident appointment calendar. Assist with coordinating transportation for medical appointments and other approved resident transportation. Prepare necessary paperwork for appointments. Notify nursing staff of upcoming appointments. Assist with obtaining appointment documentation and ensuring information is provided to the licensed nurse for review upon the resident's return. Communicate transportation needs with designated staff or approved transportation providers. Admissions, Transfers, and Discharges Assist nursing staff with clerical preparation for new admissions. Prepare appropriate forms, labels, records, and other materials needed for an admission. Assist with obtaining records from hospitals, clinics, pharmacies, or other transferring facilities. Assist with clerical responsibilities related to resident transfers and discharges. Ensure documents received following hospitalization or outside appointments are routed to the appropriate licensed nurse. Supplies and Equipment Monitor nursing unit office and documentation supplies and notify the appropriate individual when supplies need to be ordered. Maintain adequate quantities of approved nursing forms. Assist with organization of nursing supplies as assigned. Report damaged or malfunctioning office or nursing unit equipment to the appropriate department. Resident and Family Communication Greet residents, family members, visitors, providers, and others in a courteous and professional manner. Direct resident or family questions to the appropriate staff member. Immediately refer clinical questions, complaints, changes in resident condition, medication questions, or care concerns to a licensed nurse. Maintain professional boundaries and protect resident privacy at all times.

RESIDENT RIGHTS AND CONFIDENTIALITY

Protect the privacy, dignity, confidentiality, and rights of each resident. Maintain confidentiality of protected health information in accordance with HIPAA and facility policies. Avoid discussing resident information in public or unauthorized areas. Access resident information only when necessary to perform assigned job responsibilities. Immediately report suspected abuse, neglect, exploitation, mistreatment, misappropriation of resident property, injuries of unknown source, or other reportable concerns according to facility policy and applicable reporting requirements.

SCOPE OF PRACTICE

The Ward Clerk is a clerical support position and shall not independently perform duties requiring nursing judgment or professional licensure unless the employee separately holds the required license or certification and has been specifically assigned those duties. The Ward Clerk shall immediately refer questions involving resident assessment, medication administration, treatment, changes in condition, physician orders, clinical decision-making, or nursing care to a licensed nurse.

QUALIFICATIONS

Education: High school diploma or GED preferred. Medical terminology, healthcare office, unit clerk, or medical records training preferred. Experience: Previous clerical, healthcare, hospital, clinic, or long-term care experience preferred. Experience with electronic health records preferred. Knowledge and Skills: Basic knowledge of medical terminology preferred. Ability to operate computers, printers, scanners, fax systems, telephones, and other office equipment. Ability to learn and appropriately use the facility's electronic medical record and other computer systems. Strong organizational and communication skills. Ability to prioritize multiple responsibilities in a busy healthcare environment. Ability to communicate professionally with residents, families, staff, providers, and outside organizations. Ability to maintain confidentiality and appropriately handle protected health information.

PHYSICAL REQUIREMENTS

The employee must be able to perform the essential functions of the position with or without reasonable accommodation. Duties may require prolonged sitting, standing, walking, bending, reaching, use of computer equipment, handling paperwork and records, and occasional lifting or carrying of office supplies or records.

WORKING CONDITIONS

The employee works primarily within the long-term care facility and nursing department and may have regular contact with residents, visitors, healthcare personnel, and individuals with communicable illnesses. The employee must follow facility infection prevention and control practices and applicable safety procedures.

PERFORMANCE EXPECTATIONS

Maintain accurate and organized records. Complete assigned duties in a timely manner. Communicate effectively with nursing staff and other departments. Promptly route information requiring nursing follow-up. Maintain resident confidentiality. Demonstrate professionalism and dependability. Follow the facility's chain of command. Comply with facility policies, resident rights requirements, infection prevention practices, and applicable federal and Montana long-term care requirements.

OTHER DUTIES

This job description is not intended to contain a complete listing of every responsibility or activity required of the position. Duties may be modified or additional duties assigned based on facility needs, provided the duties are consistent with the employee's qualifications and applicable scope-of-practice requirements.

EMPLOYEE ACKNOWLEDGEMENT

I acknowledge that I have received and reviewed the Ward Clerk / Nursing Unit Clerk Job Description. I understand the essential duties, responsibilities, performance expectations, and limitations of this position. Employee Name: ______________________________________ Employee Signature: ___________________________________ Date: __________________ Date: __________________ Administrator Approval: _________________________________ Date: __________________ #J-18808-Ljbffr NEMHS