Ward Clerk

General Purpose

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

Essential Duties

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures

• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.

• Maintain an up-to-date roster of residents for your assigned unit.

• Fill out resident charge slips and submit to the Business Office.

• Answer telephone, page calls, deliver messages to residents, etc., as necessary.

• Maintain a current listing of emergency phone numbers for your assigned unit.

• Maintain and forward daily tardy and absentee reports to the Business Office

• Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc., as required.

• Transcribe physicians' orders to care plans, medication cards, treatment plans, etc., as required.

• Report to the Nurse Supervisor/Charge Nurse discrepancies found in transcribing physicians' orders, diet orders/changes, charting, etc.

• Review medication cards for completeness of information, accuracy in the transcription of the physician's order, legibility, etc., as directed.

• Chart nurses' notes in an informative and descriptive manner that reflects the care provided as well as 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 for transportation, packing residents' belongings, escorting them to discharge/transfer area, loading, etc., as necessary.

• Complete necessary medical and administrative records upon the resident's admission, transfer, and/or discharge.

• Forward completed charts of discharged residents to the Medical Records/Health Information Department.

• Attend various committee meetings of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment, etc.) as required.

• 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, as well as 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.

Escort to room as necessary.

• Encourage attending physicians...