Responsible for assisting the patient care team in implementing and planning patient centered care for all assigned patients on the unit during his/her shift, according to the standards of care of Central Texas Medical Center. Is able to perform basic Unit Clerk functions in all care areas. Performs duties under nursing direction.
Responsible for assisting the RN and LVN implementation and planning of patient centered care for all patients on the unit during his/her shift, according to the standards of care of Central Texas Medical Center. Is able to perform basic CNA functions in all care areas. Acts as personal care provider by attending to ongoing patient needs including, but not limited to, vital signs, personal care and ADL’s. Performs duties under nursing direction. Performs glucose checks according to policy and procedures.
Responsible for compiling and maintaining accurate documentation on each patient including, but not limited to, spiritual care, supply charges, patient and family teaching, vital signs and graphic record completion.
Reports patient condition changes, inconsistencies, or other concerns to the registered nurse and/or LVN. Follows all departmental safety policies and procedures regarding patient care and one’s personal protection and patient safety
Responsible for the planning, organizing, and coordination of activities, supplies (stock and non-stock) and equipment for the assigned unit. Manages communications, and mnemonic charge entry.
Understands the Computerized Physician Order Entry process and proficiently uses the electronic medical record for retrieval of patient information.
Understands computer downtime procedures
Monitors Electronic Medical Record for new physician orders and diagnostic results.
Understands and participates in real-time or near-time scanning of patient information/documentation, which includes:
Document Preparation: Prepares documents for scanning into the electronic document management system. Examines pages and verifies patient identification on each page.
1. Reconciles paper records with departmental documents to verify the receipt of all records.
2. Confirms patient name, medical record number, and account number on every page in the record, front and back.
3. Identifies and tape torn pages.
4. Mounts and tapes down any sheets less than 8.5 by 11 inches on an 8.5-by-11-inch mount sheet.
5. For sheets with rhythm strips or other mounted documents, tapes down the top of the strip so does not catch in the automatic document feeder (if you will be scanning in Portrait mode.
6. Removes all staples.
7. Perforates and number pages for fan-folded sheets.
8. Puts tape over sticky materials.
9. For any documents or card stock or manila, such as Kardex or ambulance run sheets, makes a photocopy before scanning.
10. Arranges multi page documents in date order, either chronological or reverse chronological, per departmental guidelines.
11. Ensures all pages are in the proper orientation.
12. If a document is identified as likely to result on poor image quality once scanned, photocopy the document, adjusting the copy contrast (lightness/darkness). This may help improve the quality of the scanned image. If improvement is not noted, follow departmental guidelines for processing-poor quality originals.
Quality Control: Reviews the electronic document management system and records contained within for appropriate image quality and indexing.
13. Determines the readiness of the batch for quality control.
14. Locates the electronic document for verification against paper batch
15. Reviews each image in the batch and verify correct patient name and account level, proper index level (encounter, section, or document), image quality (readable, orientation, multiple sides, etc.).
16. Rearranges out of order images within the electronic document.
17. Relocates electronic images that are incorrectly filed in another document or encounter.
18. Replaces electronic images that have unacceptable image quality or have been updated.
19. Modifies indexing as appropriate.
Indexing: Manually indexes documents in the correct level as establishes by facility policy. Minimizes duplicate records and overlap entries. Verifies data integrity. Coordinates information with master patient index, and patient registration modules, and various other ancillary departments and modules.
Responsible for compiling and maintaining accurate medical records from admission through discharge.
Promotes and participates in teamwork with physicians and personnel of this and other departments.
Answers call lights and responds to alarms reporting patient concerns, complaints, emergency situations to the registered nurse, LVN and/or Clinical Manager.
Follows all departmental safety policies and procedures regarding patient care and one’s personal protection and patient safety.
Develops self professionally and participates in hospital and departmental activities.
Actively participates in continuous quality improvement.
Completes other tasks as assigned.
In Women’s Services: performs hearing screens, maintenance of statistical information, performs PKU’s, connects patients to fetal monitor when requested.
Education & Experience
High school diploma or general education degree (GED).
Certificate from an accredited School of Nursing Assistants, and six months to one year related experience and/or training. Must hold a current certificate in CPR and a current certificate in CNA.
Licensure, Certification & Registration
Must hold a current certificate in BCLS.
Must hold a current certificate in C.N.A.