Responsible to: Director of Nursing. Communicates with all necessary team members.
• C.N.A. certification preferred
• High school diploma or General Education Degree (GED) preferred
• Working knowledge of Microsoft Office software applications (i.e. Word, Excel, and PowerPoint).
• Knowledge of medical terminology
• Good communication skills, both oral and written of the English language
• Ability to organize and maintain accurate records
• Must be able to read, speak and understand the English language.
• Must be able to move 20 pounds.
• Must have adequate vision and hearing to perform essential job functions.
• Must be able to propel a patient / resident in a wheelchair.
• Must be able to assist patients /residents in evacuating the building in an emergency
• Every employee in the Lexington Network must adhere to and uphold the standards set forth in our culture contract. Our common purpose, quality standards and behavioral expectations are what set us apart from other organizations. Every interaction must be approached using the ICARE expected behaviors so that every employee and resident will be treated with respect.
• The Medical Record Secretary assists the nursing department by performing clerical nursing support functions on the nursing units. These functions are necessary components of providing a high level of quality care to the resident / patients, and ensure the unit is operating effectively.
• The Medical Records Secretary is expected to handle a variety of nursing support tasks on the nursing units. The Medical Records Secretary must be able to multi-task various job duties and to organize and maintain accurate records for nursing units. This individual also becomes one of the primary contacts on the unit when communicating with patient / residents, family members, physicians, and vendors. The Medical Records Secretary will assist with directing residents / patients and family members to the appropriate person / department.
• Schedule patient care conferences (initial / discharge)
• Arrange for transportation/appointments to see the physician or for ancillary services
• Arrange transportation/appointments to see the physician or ancillary services
• Notify patients and family members of patient care conferences and prior to making appointments for their availability.
• Keep records of appointments
• Enter patients in specialized programs into the I Comet system
• Audit to ensure all documentation for care conferences and physician rounds are completed according to protocol and follow-up as indicated.
• Track Skin Checks according to daily shower schedule; follow-up and maintain.
• Acts as a liaison to visiting physicians during rounding, by assuring they have access to patients / residents medical records
• Monitor and maintain the Physician Certification/Medicare Certification form to assure completion according to regulated timeframes
• Keep an on going list of patients admitted into specialized programs.
• File returned telephone orders into the active patient record
• Maintain forms, supplies and restock as necessary to ensure accessibility.
• Answer telephones
• Answer call lights and inform appropriate staff as needed
• Respond to questions from patients, residents, families, visitors, physicians and vendors and initiate problem solving
• Communicate with pharmacy and other entities via fax and other means.
• Thin and maintain charts on a quarterly schedule and on an as needed basis (which may include reinforcing loose papers and cleaning the exterior chart).
• Obtain equipment as needed and requested.
• Record vital signs, weights, and intake and output amounts in the charts.
• Assist other team members when necessary
• All other duties as assigned
Lexington Health Care - 17 months ago