Ward Clerk Part Time

Aurora Health and RehabColumbus, MS
13d

About The Position

JOB SUMMARY: The primary purpose of the Ward Clerk position is to assist the Charge Nurses in their day-to-day recording and charting of medical and/or administrative information.

Requirements

  • Must possess a high school diploma or GED.
  • Must be able to read, write, speak, and understand the English language.
  • Must possess the ability to make independent decisions when circumstances warrant such action.
  • Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agency personnel, and the general public.
  • Must possess the ability and willingness to work harmoniously with other personnel.
  • Must have patience, tact, a positive attitude and enthusiasm, as well as the willingness to handle difficult residents.
  • Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.
  • Must be able to relate information concerning a resident’s condition.
  • Must not pose a direct threat to the health and safety of other individuals in the workplace.
  • Must be able to move continuously throughout the workday.
  • Must be able to cope with the mental and emotional stress of the position.
  • Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
  • Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, families, personnel, and support agencies.
  • Must meet the general health requirements set forth by the policies of this facility, which may include a medical and physical examination.
  • Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at times, hostile people within the facility.
  • Must be able to push, pull, move, and/or lift a minimum of 10 pounds to a minimum height of 5 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 5 feet.
  • May be necessary to assist in the evacuation of residents during emergency situations.

Responsibilities

  • Record medical and administrative information in accordance with our established charting and documentation policies and procedures.
  • Maintain the Daily Census Report and submit to Charge Nurse.
  • Main an up-to-date roster of residents for your assigned unit.
  • Fill out resident charge slips and submit to the Business Office.
  • Answer telephone, page calls, deliver messages to residents, etc. as necessary.
  • Maintain a current listing of emergency phone numbers for your assigned unit.
  • Maintain and forward daily tardy and absentee reports to Business Office.
  • Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc. as required.
  • Transcribe physicians’ orders to care plans, medication cards, treatment plans, etc., as required.
  • Report to the Charge Nurse discrepancies found in transcribing physicians’ orders, diet orders/changes, charting, etc.
  • Review medication cards for completeness of information, accuracy in the transcription of the physicians’ order, legibility, etc, as directed.
  • Chart nurses’ notes in an informative and descriptive manner.
  • Record vital signs as directed.
  • Forward new diet orders and/or diet changes to the Food Service Manager.
  • Keep nursing service personnel informed of residents’ appointments.
  • Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
  • Notify the resident’s next-of-kin when there is a change in the resident’s condition.
  • Notify, as instructed, the resident’s, the residents next-of-kin when the resident is involved in an accident or incident.
  • Fill out and complete accident and incident reports as directed.
  • Admit, transfer, and discharge residents. Assist in arranging for transportation, packing residents’ belongings, escorting them to discharge/transfer area, loading, etc. as necessary.
  • Complete necessary medial and administrative records upon the resident’s admission, transfer, and/or discharge.
  • Notify the Charge Nurse should a resident be discharged without a physician’s order.
  • Forward completed charts of discharged residents to the Medial Records Department.
  • Pick up mail from box in a.m. and file.
  • File items in baskets daily.
  • Take telephone orders to Medical Records daily.
  • Take charts to Medical Records after death or discharge once physician signs orders.
  • Go through charts daily to check for loose papers.
  • Purge all charts on a quarterly basis
  • Keep records of telephone orders when going out and returned.
  • Day after admission put face sheets on charts.
  • Direct visitors to resident rooms, office areas, as necessary.
  • Attend various committee meetings of the facility as assigned.
  • Assist in preparing written and/or oral reports of the nursing service programs and activities to submit to such committee as directed.
  • Provide data to the Quality Assurance & Assessment Committee as requested.
  • Participate in developing the agenda for the Care Plan Committee meetings as necessary.
  • Implement recommendations from established committees as instructed.
  • Assist in the orientation of newly assigned personnel as directed.
  • Interpret department policies and procedures to personnel, residents, visitors, etc. as directed.
  • Develop and maintain a good working rapport with inter-departmental personnel, as well as other department within the facility.
  • Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.
  • Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.
  • Greet newly admitted residents upon admission. Escort to room as necessary.
  • Assist in escorting residents to/from activity and social functions.
  • Report administrative problem areas to the Charge Nurse. Assist in developing and implementing corrective action.
  • Inform family members as necessary of the death of a resident as directed.
  • Call funeral homes when requested by family and directed by Charge Nurse.
  • Follow established safety regulations in the use of equipment and supplies.
  • Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.
  • Assist in maintaining nursing service work areas in a clean and sanitary manner.
  • Participate in the implementation and maintenance of the infection control program for monitoring communicable and/or infectious diseases, including TB, among the residents and personnel.
  • Follow established infection control procedures when isolation precautions become necessary.
  • Follow established procedures in the use and disposal of personal protective equipment.
  • Report hazardous conditions or equipment to the Charge Nurse.
  • Follow established Universal Precautions techniques.
  • Inform the Charge Nurse of your equipment and supply needs
  • Follow established preventive maintenance procedures for maintaining your equipment and supplies in a safe and operable manner.
  • Transcribe data to the care plan as necessary.
  • Maintain the confidentiality of all resident care information.
  • Treat all residents fairly, and with kindness, dignity, and respect.
  • Knock before entering the resident’s room.
  • Review complaints made by the residents and make a written/oral report to the Charge Nurse. Follow facility’s established procedures.
  • Maintain a written record of the resident’s complaints that indicates the action taken to resolve the complaint and the current status of the complaint.
  • Report all allegations of resident abuse and/or misappropriation of resident property
  • Attend in-service training programs as scheduled.
  • Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and blood borne pathogen standards.
  • Attend and participate in advance directive in-service training programs for the staff.
  • Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession.
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