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.
Indeed - 9 months ago
- 8 days ago
CNA/Ward Clerk 3rd shift
AdCare Hospital of Worcester, Inc.
AdCare Hospital of Worcester, Inc.
- 2 days ago