General clerk h1.location_city

Aventura at Prospect -

POSITION SUMMARY

The Unit Clerk is responsible for assisting in the recording or charting of resident information in accordance with the Nursing Department’s policies and procedures.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Maintains an accurate chart on each resident:

a. On admission will put together a chart. Reviews records sent with resident and places them on chart making sure all headings are filled in. Will contact hospital’s Medical Records Department if any are missing or need to be sent.

b. Records intake and output if necessary on a daily basis.

c. Charts TPR, blood pressure, and weight on a regular basis.

d. Check date of CBC, UA, and History and Physical making sure they are done on a yearly basis. Calls attention to M.D. if needed to be ordered.

e. Flags areas on charts that need physician signatures.

f. Notify physician if they are due to make rounds.

g. Obtain information from admission regarding resident’s level of care and status as to Medicare, Medicaid, or Private pay and labels charts.

h. Check charts making sure documents are in proper sequence.

2. Keeps an up-to-date ongoing file on each resident per dictated by Medical Records.

a. Purges charts on a regular basis and files in resident’s envelope on the nursing unit.

b. On discharge, removes all charts, files, and records of resident from nursing unit it Medical Records.

c. Audits charts on a routine basis.

3. Communicates needs to other Departments within the facility in relation to residents care and needs of the unit itself.

a. Notifies Physical Therapy of an order to evaluate a resident.

b. Informs Dietary of any changes in a resident’s diet, room change, or discharge from facility.

c. Makes appointments for the beauty shop and barber when applicable.

d. Notifies the Business Office of any change in resident’s level of care, status, or room change.

e. Keeps Housekeeping informed of any needs on the unit.

f. Documents repairs within the unit to be handled by the Maintenance Department.

4. Communicate appointments needed to the Transport Aid necessary for their care.

5. Keeps a complete file of forms and supplies needed for accurate documentation by nursing personnel.

a. Fills out restraint sheets, monthly vitals sheet, I&O book, BM records for their proper use.

b. Keeps an accurate Shower List, Diabetic List, Physical Therapy List, Ambulation List, and daily charting list.

c. Keeps bulletin board up-to-date.

d. Copies forms needed by nursing personnel for charting.

e. Fills out lab request forms and files on a monthly or however ordered.

f. Keeps memo book.

g. Under supervision, will do medication and treatment sheets, Doctor’s Orders, and Nurse Aide flow sheets.

h. Transcribes orders and communicates appropriate orders to initiate care.

6. Maintain resident confidentiality and privacy.

7. Treat residents with kindness, dignity, and respect.

8. Responsible for maintaining supplies needed for nursing care.

a. Check supplies in treatment room on a daily basis and communicates needs to Central Supply.

9. Must be able to communicate with families of residents, i.e. Public Relations.

a. Responsible Parties must be notified should resident be sent to the hospital, need to be transferred to another room, transportation, or anything involving extra costs.

10. Demonstrate ability to prioritize tasks, organize work load, and maintain a neat stocked work area.

11. Participate in in-service training classes, seminars, and continuing education as deemed necessary.

12. Maintain professional competence.

General Responsibilities

1. Performs all tasks and duties in an efficient and safe manner.

2. Performs other related duties as assigned or as necessary. Remains flexible and adaptable in work schedules and work assignments as defined by departmental and organizational needs.

3. Represents Reliant Senior Care in a manner that conveys professionalism, confidentiality, courtesy, fairness, personal integrity, and respect for others.

QUALIFICATIONS

A. EDUCATION AND/OR EXPERIENCE

• High School diploma required

• Must be at least 18 years of age

• CNA certified

B. SKILLS AND ABILITIES

• Ability to read and write in a legible and understandable manner

• Excellent written and oral communication skills required

• Ability to remain calm under stress

• Must have a positive attitude toward the elderly

• Must speak and understand English