Medical Records

Caraday Healthcare • San Angelo, TX

7d • Onsite

About The Position

Under the supervision of the professional nurse, performs a variety of clerical duties associated with patient care unit operations.

Requirements

• High school diploma or equivalent (GED)
• Ability to type
• General computer knowledge
• Good written and verbal communication skills
• The ability to safely perform movements such as pushing, pulling, lifting, bending, kneeling, and reaching up to 25 pounds with or without reasonable accommodations

Nice To Haves

• PCC & SimpleLTC software
• Prior experience entering orders into computer
• Knowledge of medical terminology
• Good written and verbal communication skills

Responsibilities

• Written and verbal communication with members of the healthcare team, patients, and visitors utilizing equipment such as the telephone and intercom
• Maintain confidentiality of patient information
• Assemble, complete, and process patient charts as indicated
• Keep patient records accurately identified; maintain an accurate clinical record, recording information per facility policy
• Transcribe doctors’ orders per facility policy
• Perform daily review of charts for incomplete histories and operative summaries; bringing any compliance issues to the attention of the appropriate member of the health care team for correction
• Obtain closed records from Medical Records as needed
• Initiate required nursing forms for new admissions and at month end
• Order unit supplies to maintain inventory stock and supplies; assist with receiving, distributing and sorting supplies brought to the unit
• Maintain an orderly and businesslike environment at the nursing station in order to assist members of the health care team in the performance of their jobs despite high-stress factors
• Promote positive public relations with patients, residents, family members, and guests
• Use tactful, appropriate communications in sensitive and emotional situations
• Use appropriate workplace behavior and adhere to dress code at all times
• Understand and adhere to the guidelines of “Residents Rights” and assure resident safety
• Other duties as assigned

What This Job Offers

• Career Level: Entry Level
• Education Level: High school or GED