Preforms clerical and reception functions for the area assigned. Assists nurses in their daily recording and charting of medical or administrative information in accordance with federal, state and local guidelines and Marwood Nursing & Rehab policy and procedures.
JOB DUTIES AND RESPONSIBILTIES:
The following description of job responsibilities and standards is intended to reflect the major responsibilities and essential duties of the job but is not intended to describe minor duties or other responsibilities as may be assigned from time to time:
Completes all secretarial duties for areas assigned as directed by nurse, physician and/or supervisor up to and including chart assembly, answering telephones, directing visitors, coping, faxing, sorting, filing, mailing,
Responsible for the coordination and filing of all open charts and forms in the all neighborhoods and nursing locations. Will complete monthly audits and thins charts as needed.
Contacts physicians as needed to assure timely visits according to facility policy and procedure. Will report noncompliance to the Medical Records Supervisor.
Pulls charts for physician rounding. Maintains resident roster by physician for area assigned.
Will send physician orders daily to assure timely signatures. Will ensure orders are in compliance. Review physician orders for lab work and chest x-ray orders; fax physician telephone orders to pharmacy as needed.
Assists with admitting and transferring/discharge of residents.
Performs resident care in accordance to Certified Nurse Aide standards as needed including meal service, bathing, dressing, and personal care. Will answer call lights and provide assistance as appropriate. May be reassigned duties to perform CNA tasks intermittently at the request of Nursing Leadership and/or Medical Records Supervisor.
Copies physician orders to chart for nurse review; will transcribe orders as needed.
Stamps all admitting physician orders and other required documents according to facility policy.
Analyzes and audits open charts for completeness of forms and charting requirements. Will notify appropriate supervisor of deficiencies.
Will make consultation arrangements for ancillary services (dental, podiatry, vision, etc.). Coordinates resident transportation with resident, families and staff.
Will process completed guardianship papers and Medical Advance Directives.
Maintains lab schedule per lab policy and procedure
Distributes unusual occurrence forms to appropriate individuals
Protects organization's value by keeping resident's personal health information confidential per HIPAA guidelines.
Adheres to facility's safety and infection control policies.
Participates in and completes all mandatory in in-services and educational opportunities as directed; maintains professional certification.
Performs other duties as assigned.
Adheres to McLaren Health System Standards of Conduct, facility's policies and procedures as well as federal, state, and local regulations.
Equal Opportunity Employer of Minorities/Females/Disabled/Veterans
KNOWLEDGE, SKILLS AND ABILITIES:
Education: High school diploma or GED; Current Certified Nurse Aide Certificate
Experience: Previous geriatric experience preferred
Must be able to communicate in English both verbally and in writing. Must demonstrate computer literacy including use of computer programs and applications.
Office/clerical experience; medical terminology knowledge preferred
PHYSICAL AND COGNITIVE REQUIREMENTS:
Position requires ability to frequently lift objects up to 35 pounds and to push/pull objects more than 45 pounds; manual dexterity to frequently perform difficult manipulative tasks; gross body coordination to walk, stand, stoop, etc., hand-eye coordination to perform tasks such as keyboard skills, etc. and tasks which require arm-hand steadiness such as taking B/Ps and calibration of equipment; visual discrimination for completing resident assessment; audio discrimination adequate to hear normal sounds with some background noise and to distinguish voice patterns, auscultation; able to concentrate on fine detail with some interruption and moderate detail with frequent interruptions, ability to frequently attend to task/function for 10-20 minutes at a time and occasionally for 20-45 minutes at a time; ability to remember multiple tasks/assignments given over long periods of time.
Environment and Working Conditions:
Works in long term care and rehab healthcare setting with residents who are experiencing a wide range of medical, surgical, end of life, and /or psychological problems. Flexible work schedule required.
Work on resident units, nurses' stations, resident rooms, medication rooms, therapy areas, lounges, and all parts of the facility where resident care may be rendered.Occasionally may be required to exit the premises in the pursuance of medical needs either directly for the facility or resident. Exposure to blood, body tissue, and other infectious fluids.
Northern Michigan Hospital