Nursing - Unit Clerk
St. Patrick's Manor - Framingham, MA

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Job Summary: The Unit clerk is responsible for performing duties to assist unit nurse in preparing, compiling, and maintaining accurate and timely records on each resident

Essential Duties and Responsibilities:

  • Verify census daily.
  • Assure that all medical record information is protected and kept confidential.
  • Protect all medical record information from loss, defacing, or destruction before retention period.
  • File medical records and maintain files according to state regulations
  • Retrieve medical records upon request
  • Identify incomplete documentation and report to individuals responsible for completion
  • Identify inaccurate documentation and report to individuals responsible for accuracy of documentation
  • Advise all disciplines of documentation to be completed or corrected
  • Thin overflow from in-house records, audits, and file in discharge record order
  • Keep charts orderly and thinned according to state regulations
  • Maintain additional diagnosis sheet, computer interim sheets and computer change of information sheets
  • Verify diagnoses with Nurse Service and record on admission record
  • Assure that all information is complete on admission record and record is placed in medical record
  • Ensure that all medical record forms for resident identification information are placed in medical record
  • Audit medical records, as assigned
  • See that routine labs, weekly, etc. are done
  • Assure laboratory and X-ray reports are received and filed for all tests completed
  • Make appointments with Laboratory and X-ray for tests to be performed
  • Audit transfer/discharge information to assure accuracy and completeness
  • Distribute Discharge Referral (copy to: VNA, attending physician post discharge and the chart
  • Assist with processing of computer forms, as assigned, identification
  • Assist with quality assessment and assurance studies
  • Assist nurse in checking physician’s orders
  • Maintain accurate records for routine visits, yearly physicals, pro-op physicals, updates, and scheduled tests
  • Weekly set up for doctors day according to regulations
  • Pull all P.T. orders and hand deliver to P.T. monthly. Also new Medicare A & B forms (signed by M.D. weekly and hand delivered to P.T. and put into special folder
  • Review doctor day with nurse weekly; include treatment sheets, flow sheets, treatment book & PT list
  • Prepare interim sheets for Drug pickup, pull carbons and send to Pharmacy Corp. of America monthly
  • Order meds, Med B supplies daily; weekly orders are done by med nurses except on floors A1 & B1
  • Setup for physicians visits, review physician order sheet every 60 days and every 30 days
  • Transcribe orders (Weekly physician onto med sheet and treatment sheets, pick up all consults, orders, x-rays, labs, doctors’ appointments, 02, dental, new orders on return from hospital and appointments, etc.
  • Transport residents
  • Order office supplies
  • Put supplies away in appropriate storage spaces
  • Complete information for Insurance carriers and obtain necessary M.D. signatures
  • Maintain current information on ADL cardex sheets
  • Answer telephone and route calls
  • Assist Medical Record Designee, as assigned. (gather info. for insurance forms)
  • Assist nursing staff, as assigned
  • Assist administrative staff, as assigned
  • Perform other related duties as directed

Physical Demands: Good standing balance, defined as the ability to stand and walk without a loss of balance; good range of motion; normal upper extremity strength; good lower extremity range of motion; normal lower extremity strength; good trunk range of motion and good cervical range of motion.