Ward Clerk - Medical Records
Vanguard Healthcare Services 1.818 reviews - Savannah, GA

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Regional skilled nursing facility is seeking a Ward Clerk for their skilled nursing unit. The primary purpose of your job position is to assist the Charge Nurses in their day-to-day recording and charting of medical and/or administrative information Administrative Functions Record medical and administrative information in accordance with our established charting and documentation policies and procedures. Maintain the Daily Census Report and submit to Charge Nurse. Main 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 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 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 physicians’ order, legibility, etc, as directed. Chart nurses’ notes in an informative and descriptive manner. Record vital signs as directed. Forward new diet orders and/or diet changes to the Food Service Manager. Keep nursing service personnel informed of residents’ appointments. Assist in arranging for and making resident appointments for diagnostic and therapeutic services. Notify the resident’s next-of-kin when there is a change in the resident’s condition. Notify, as instructed, the resident’s, the residents next-of-kin when the resident is involved in an accident or incident. Fill out and complete accident and incident reports as directed. 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 medial and administrative records upon the resident’s admission, transfer, and/or discharge. Notify the Charge Nurse should a resident be discharged without a physician’s order. Forward completed charts of discharged residents to the Medial Records Department. Pick up mail from box in a.m. and file. File items in baskets daily. Take telephone orders to Medical Records daily. Take charts to Medical Records after death or discharge once physician signs orders. Go through charts daily to check for loose papers. Purge all charts on a quarterly basis Keep records of telephone orders when going out and returned. Day after admission put face sheets on charts. Direct visitors to resident rooms, office areas, as necessary.
Committee Functions Attend various committee meetings of the facility as assigned. Assist in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee as directed. Provide data to the Quality Assurance & Assessment Committee as requested. Participate in developing the agenda for the Care Plan Committee meetings as necessary. Implement recommendations from established committees as instructed.
Personnel Functions Assist in the orientation of newly assigned personnel as directed. Interpret department policies and procedures to personnel, residents, visitors, etc. as directed. Develop and maintain a good working rapport with inter-departmental personnel, as well as other department within the facility. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
Nursing Care Functions 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. Assist in escorting residents to/from activity and social functions. Report administrative problem areas to the Charge Nurse. Assist in developing and implementing corrective action. Inform family members as necessary of the death of a resident as directed. Call funeral homes when requested by family and directed by Charge Nurse.

Staff Development Attend in-service training programs as scheduled. Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and blood borne pathogen standards. Attend and participate in advance directive in-service training programs for the staff. Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession.
Safety and Sanitation Follow established safety regulations in the use of equipment and supplies. Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids. Assist in maintaining nursing service work areas in a clean and sanitary manner. Participate in the implementation and maintenance of the infection control program for monitoring communicable and/or infectious diseases, including TB, among the residents and personnel. Follow established infection control procedures when isolation precautions become necessary. Follow established procedures in the use and disposal of personal protective equipment. Report hazardous conditions or equipment to the Charge Nurse. Follow established Universal Precautions techniques.
Equipment and Supply Functions Inform the Charge Nurse of your equipment and supply needs Follow established preventive maintenance procedures for maintaining your equipment and supplies in a safe and operable manner.
Care Plan and Assessment Functions Transcribe data to the care plan as necessary.
Resident Rights Maintain the confidentiality of all resident care information. Treat all residents fairly, and with kindness, dignity, and respect. Knock before entering the resident’s room. Review complaints made by the residents and make a written/oral report to the Charge Nurse. Follow facility’s established procedures. Maintain a written record of the resident’s complaints that indicates the action taken to resolve the complaint and the current status of the complaint. Report all allegations of resident abuse and/or misappropriation of resident property.

Education Must posses a high school diploma or GED. Prefer a certificate in medical assistant training or related coursework.
Specific Requirements Must be able to read, write, speak, and understand the English language. Must possess the ability to make independent decisions when circumstances warrant such action. Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agency personnel, and the general public. Must possess the ability and willingness to work harmoniously with other personnel. Must have patience, tact, a positive attitude and enthusiasm, as well as the willingness to handle difficult residents. Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices. Must be able to relate information concerning a resident’s condition. Must not pose a direct threat to the health and safety of other individuals in the workplace. Physical and Sensory Requirements Must be able to move intermittently throughout the workday. Must be able to speak and write the English language in an understandable manner. Must be able to cope with the mental and emotional stress of the position. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met. Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies. Must meet the general health requirement set forth by the policies of this facility, which include a medical and physical examination. Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at time hostile people within the facility. Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination. Must be able to push, pull, move, and/or lift a minimum of five (5) pounds to a minimum height of three (3) feet and be able to push, pull, move, and/or carry such weight a minimum distance of five (5) feet. Must be able to assist in the evacuation of residents during emergency situations. Sitting: 5-6 hour per 8-hour shift. Alternates frequently to standing or walking. Standing: 1-2 hours per 8-hour shift. Alternates frequently to walking and occasionally to sitting. Walking: 1-2 hours per 8-hour shift. Alternates frequently to standing and occasionally to sitting. Lifting: 1-10 lbs. Continuously
11-20 lbs. Occasionally
21-75 lbs. Rarely
> 75 lbs. Rarely Carrying: 1-10 lbs. Continuously
11-20 lbs. Occasionally
21-35 lbs. Rarely Driving: Rarely Pushing: Occasionally Bending: Frequently Squatting: Occasionally Kneeling: Occasionally Crawling: Rarely Climbing: Rarely Reaching: Continuously Grasping: Frequently Fine Manipulation: Frequently
(Frequency: Never=0%; Rarely=1-10%; Occasionally=11=33%; Frequently = 34-66%; Continuously = 67%+)
Equal Employment Opportunity/Affirmative Action Employer and does not discriminate on the basis of race, color, age, sex, religion, national origin, disability, marital status, or any other characteristic protected by law.

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1.818 reviews