Unit Ward Clerk

JOB DESCRIPTION

Unit-Ward Clerk

Department: Nursing

FLSA Classification: Non-exempt

Reports to: Director of Nursing

Overview of the position: 

The Unit-Ward Clerk role involves supporting the Director of Nursing and Unit Managers by monitoring the completion of records as well as nursing station organization.

Responsibilities:

Records Management Functions

Admissions:

• Initiate/coordinate admission process.

• Complete admission checklist.

• Conduct tours of the facility with prospective admissions.

During the Resident stay:

• Thin in-house records in accordance with the written policy and procedure and files in discharge chart order for the in-house overflow file.

• Maintain in-house chart appearance and organization.

• Maintain a monitoring system to assure telephone orders and other information are signed and returned by the physician or other professionals.

• File all incoming clinical information in the in-house records on a daily basis.

• Check telephone orders daily for transcription on physician’s orders, medications and treatment records, care plants, etc.

• Monitor timeliness of physician’s visits on a monthly basis in conjunction with the manager of health information services.

• Prepare paperwork for transfer or referrals.

• Photocopy documents.

• Act as a liaison between Nursing and other departments.

• Protect the privacy and security of health information and follow confidentiality and release of information procedures.

• Audits of resident’s records as requested.

• Follow the safety guidelines and regulations set forth by the facility.

• Follows emergency action plan.

Discharge:

• Prepare paperwork for discharge

• Assemble record from the nursing station and the overflow files in established discharge order

• Performs additional duties and assignments, as requested

Qualifications for the position:

• Minimum Entry Level

• General office skills including filing, organizing, and tracking

• Oral and written communication skills

• Good customer service and telephone skills/etiquette.  Tact and warmth when dealing with family and residents

• Ability to work within a team

• Empathy for the elderly

• Ability to work systematically and without continuous supervision

Acknowledgement: 

Every effort has been made to identify the essential functions of this position.  However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the opposition if the work is similar, related, or is an essential function of the position.

I have read this job description and understand the requirements set forth therein.  I agree to perform the identified essential functions in a safe manner and in accordance with the facility’s established procedures.  I understand that as a result of my employment, I may be exposed to blood, body fluids, infectious disease, air contaminants (including tobacco smoke, and hazardous chemicals and that the facility will provide to me instructions on how to prevent and control such exposures.  I further understand that I may also be exposed to the Hepatitis B Virus and that the facility will make available to me, free of charge, the hepatitis B vaccination.  

I understand that my employment is at-will, and thereby understand that my employment may be terminated at-will either by the facility or myself, and that such termination can be made with or without notice.

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Signature, Unit-Ward Clerk                                     Date

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Signature, Director of Nursing  Date