Ward Clerk (non-licensed) - Antelope Valley Care Center

PACS

6d•$19 - $21

About The Position

The Ward Clerk assists the Nurse Supervisor/Charge Nurse with day-to-day recording and charting of medical and administrative information, following applicable standards and facility policies to ensure medical records are informative and descriptive. The role supports resident admissions, transfers, and discharges; communication among residents, families, and staff; and the maintenance of unit records and reports. This position has no supervisory responsibilities. The Ward Clerk must have a high school diploma or GED and exceptional communication and customer service skills. Basic knowledge of medical terminology and nursing practices is helpful. The role requires the ability to read and interpret business, professional, technical, and regulatory materials; write reports and correspondence; present information; apply basic mathematical concepts; and solve practical problems. The employee occasionally lifts or moves up to 25 pounds and may need to assist with resident evacuation during emergencies. The work involves prolonged computer use and regular sitting, standing, walking, talking, reading, or hearing, as well as frequent use of office equipment. The work environment typically has low to moderate noise.

Requirements

High school diploma or GED.
Exceptional communication and customer service skills.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, and governmental regulations.
Ability to write reports, business correspondence, and procedure manuals.
Ability to present information effectively and respond to questions from managers and employees.
Ability to apply fractions, percentages, ratios, and proportions to practical situations.
Ability to solve practical problems and work with concrete variables in situations with limited standardization.
Ability to interpret written, oral, diagrammatic, or schedule-based instructions.
Ability to occasionally lift and/or move up to 25 pounds.
Ability to use a desktop or laptop computer for prolonged periods and regularly sit, stand, walk, talk, read, or hear.
Ability to use office equipment, including a copier/scanner/fax, telephone, and calculator.
May be necessary to assist in the evacuation of residents during emergency situations.

Nice To Haves

Basic knowledge of medical terminology and nursing practices.

Responsibilities

Record medical and administrative information according to established charting and documentation policies and procedures.
Maintain the Daily Census Report and submit it to the Nurse Supervisor/Charge Nurse.
Maintain an up-to-date roster of residents for the assigned unit.
Complete resident charge slips and submit them to the Business Office.
Answer telephone calls, page calls, and deliver messages to residents as necessary.
Maintain a current listing of emergency phone numbers for the assigned unit.
Maintain and forward daily tardy and absentee reports to the Business Office.
Record resident identification information on designated medical records, wristbands, and ID cards as required.
Transcribe physicians’ orders to care plans, medication cards, and treatment plans as required.
Report discrepancies in transcribed orders, diet orders or changes, and charting to the Nurse Supervisor/Charge Nurse.
Review medication cards for completeness, accuracy, and legibility as directed.
Chart nurses’ notes informatively and descriptively, reflecting care provided and the resident’s response.
Forward new diet orders and diet changes to the Director of Food Services.
Notify a resident’s next of kin of changes in the resident’s condition as instructed.
Admit, transfer, and discharge residents; assist with transportation arrangements, packing belongings, and escorting or loading residents as necessary.
Complete required medical and administrative records for resident admissions, transfers, and discharges.
Forward completed charts of discharged residents to the Medical Records/Health Information Department.
Attend facility committee meetings as required.
Assist the Nurse Supervisor/Charge Nurse with developing work assignments and schedules as required.
Maintain a good working rapport with inter-departmental personnel and other facility departments.
Inform nursing service personnel about new admissions, expected arrival times, and room assignments.
Greet newly admitted residents and escort them to their rooms as necessary.
Encourage attending physicians to record and sign progress notes and orders promptly and in accordance with regulations.
Inform family members of a resident’s death as instructed and call funeral homes when requested by the family.
Attend and participate in scheduled annual facility in-service training programs.
Participate in appropriate in-service training before performing tasks involving potential exposure to blood or body fluids.
Participate in implementing and maintaining the infection control program, including monitoring communicable or infectious diseases such as TB among residents and personnel.
Inform the Nurse Supervisor/Charge Nurse of equipment and supply needs.
Ensure personnel involved in resident care are aware of the resident’s care plan and that nursing personnel refer to it before providing daily care.
Report suspected or known fraud related to false billings, cost reports, kickbacks, or similar matters.
Treat residents fairly and with kindness, dignity, and respect.
Assist with recording incidents and accidents and file records according to established policies and procedures.
Protect residents’ health information and promptly report suspected or known violations of disclosure requirements to the Administrator.
Perform other duties assigned by the supervisor, Director of Nursing, or Administrator.