Ward Clerk

General Purpose 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 federal, state, and local standards, guidelines, and regulations that govern medical records. Essential Duties 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 them to the Business Office. Answer telephone and page calls, and deliver messages to residents as necessary. Maintain and forward the current list of emergency phone numbers for the unit. Maintain and forward daily tardy and absentee reports to the Business Office. Record appropriate resident identification data on designated medical records, wristbands, and ID cards as required. Transcribe physicians’ orders to care plans, medication cards, and treatment plans as required. Report discrepancies in transcribing physicians’ orders, diet orders/changes, and charting to the Nurse Supervisor/Charge Nurse. Review medication cards for completeness, accuracy, and legibility as directed. Chart nurses’ notes in an informative and descriptive manner that reflects the care provided and the resident’s response. 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 belongings, escorting them to the discharge/transfer area, and loading 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 committee meetings (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment) as required. Assist the Nurse Supervisor/Charge Nurse in developing work assignments and schedules 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, expected time of arrival, and room assignment. Greet newly admitted residents and escort them to their rooms as necessary. Encourage attending physicians to record and sign progress notes and physicians’ orders on a timely basis and in accordance with regulations. Inform family members of the death of a resident 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 programs prior to 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 that 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 related to false billings, cost reports, kickbacks, etc. Treat all residents fairly, with kindness, dignity, and respect. Assist in recording all incidents/accidents and file them in accordance with established policies and procedures. Agree not to disclose protected health information and promptly report suspected or known violations to the Administrator. Other duties as assigned by the supervisor/DON/Administrator. Qualification Education and/or Experience Must possess, as a minimum, a high school diploma or GED and have exceptional communication and customer service skills. Language Skills Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from managers and employees. Mathematical Skills Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Reasoning Ability Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Certificates, Licenses, Registrations A basic knowledge of medical terminology and nursing practices is helpful. Physical Demands The employee must occasionally lift and/or move up to 25 pounds, use a desktop or laptop computer, sit, stand, walk, talk, read, and hear. Frequent use of office equipment (copier, scanner, fax, telephone, calculator) is required. The employee may be required to assist in the evacuation of residents during emergency situations. Work Environment The noise level is usually low to moderate. Reasonable accommodations may be made for individuals with disabilities. We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status. #J-18808-Ljbffr