Ward Clerk/Unit Secretary U

Montefiore Health System•New York, NY

1d•Onsite

About The Position

The Unit Secretary is responsible for the flow of information inter/intra unit and between members of the patient care team. Additionally, the unit secretary functions as a receptionist while performing secretarial and routine administrative duties. The unit secretary's primary role is integrity and maintenance of the medical record from admission to discharge, ordering supplies, and coordination of the movement of patients on the assigned unit. Utilizes effective interpersonal skills to communicate and collaborate effectively with the Interdisciplinary Care Team.

Requirements

High School Diploma or GED Required.
1-3 years clinical experience
Effective English communication skills, both written and oral.

Responsibilities

Provides assistance/supervision during activities of daily living such as eating, bathing, and ambulating as appropriate for the neonatal, pediatric, adolescent, adult or elderly patient.
Meets the hygiene and grooming needs of patients including bathing, shaving, hair care, oral care, and perineal care.
Meets patient’s need for mobility by performing activities such as range of motion, assisting with ambulation, transferring from bed to chair or stretcher and applying splints and braces
Participates in maintaining patients skin integrity through utilization of pressure relieving devices, turning, and positioning, and assisting in pressure ulcer care.
Provides patient comfort measures such as bed making positioning and body alignment and back rubs.
Assists patients with elimination needs (including administration of cleansing enemas) provides urinary catheter care, measures and documents output and participates in bowel and bladder retraining according to policy and procedure.
Assists in providing and maintaining a safe environment for the patient through observation and alternative interventions, including safety/ environmental rounds, response to call bells utilizing Montefiore Excellence Standards.
Provides for patient’s need for rest and sleep by maintaining a quiet environment.
Maintains body substance precautions and follows infection control policies within the institution.
Obtains and documents vital signs as directed including temperature, blood pressure, pulse, respiration, pain score, height, and weight. Reports variations from baseline to RN and documents the notification.
Obtains specimens such as urine, stool, sputum, and documents as required. Notifies RN if not complete
Administers hot and cold applications to patients as directed.
Assists in preparing patients for surgery.
Assists in performing diagnostic and therapeutic treatments
Provides assistance during emergency procedures as directed
Provides post-mortem care and transports patient to morgue as assigned.
Admits patient to unit upon arrival including provision of comfort supplies (gown, tissues, H20); completes unit orientation checklist, patient clothing/ property list.
If patient is transferred or expires, packs patients’ belongings, and transports them to appropriate area.
Provides patient care in accordance with policies and procedures for side rails, physical restraints, periodic awareness, and constant observation.
Maintains a clean and neat environment including soiled linen disposal.
Provides for a safe environment to protect the patient from injury that is appropriate to the population of the patient, i.e. neonatal, infant, child, adolescent, adult or geriatric.
Accompanies patients being admitted and/or transferred to the nursing unit.
Transports patients to and from diagnostic procedures and to other hospital locations.
Transports patient’s medical record to designated hospital locations as directed by R.N.
Replaces and/or restocks supplies and transports supplies and equipment within assigned clinical unit.
Maintains utility and service rooms in proper order as assigned.
Performs equipment checks as assigned.
Follows infection control policies and procedures.
Answers patient call lights immediately without walking past a call light or a patient, family, visitor, coworker requesting assistance.
Refers questions from patients and families to the R.N.
Maintains patient’s confidentiality and privacy.
Documents accurately in the patient’s medical record.
Communicates in a manner, which is courteous and appropriate to the age of the patient and/or family.
Reports observations and changes in patient condition to the R.N.
Asks questions and seeks clarification as necessary from the R.N.
Conforms to established dress code policy and projects a professional demeanor.
Completes assignments within time scheduled.
Introduces self to patients/families/visitors at the beginning of the shift and ongoing as indicated, updates white board daily.
Presents self as a member of the unit team extending assistance to all departments and disciplines.
Complies with the MMC policies for attendance and sick call procedure.
Complies with unit practices for meal periods breaks, requesting time off.
Participates in assigned Performance Improvement activities.
Complies with Nursing policies and procedures.
Performs job functions in a manner that promotes efficient use of resources.
Reports unsafe conditions to the R.N.
Respects the rights of patients as delineated in the “Patient Bill of Rights”.
Attends educational programs related to practice.
Performs other related duties as assigned by the Administrative Nurse Manager, Assistant Administrative Nurse Manager, Patient Care Coordinator, or charge nurse.