Unit Clerk - Medsurg

Description

JOB SUMMARY

Under the general direction of the Registered Nurse on duty and to the Director of Nursing and Clinical Services, the Unit Clerk is responsible for performing general secretarial receptionist and clerical duties in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast paced and dynamic environment.  

STANDARDS OF PERFORMANCE

1. Ensures adherence to proper infection control, OSHA and safety standards.
2. Prepares charts for patients ensuring inclusion and completion of: Surgical checklist (when applicable), Nursing Problem List, Physicians Order Sheet, Nurses Notes, Medication Administration Record, History and Physical, Progress Record, Laboratory Reports Sheet, Graphic Sheet, and Nursing Assessment.
3. Prepare Chart labels using color code.
4. Correctly maintains the daily census sheet.
5. Prepares Nursing Kardex Cards recording patient name, diagnosis, physician, age, room, hospital number, allergies, etc.
6. Using the addressograph card to stamp all chart forms upon admission of patient or addition to chart.
7. Transcribes the Physician’s Orders in an accurate and timely manner.
8. Prepares and routes patient request slips as necessary (EKG, Respiratory Therapy, Lab, X-Ray, etc.)
9. Transcribe information from worksheets to patient charts as necessary. (TPR, Allergies, I & O, STA, etc.)
10. Answers telephone and intercom accurately relaying messages.
11. Secures records from previous admissions. Prepares charts for transfer or dismissal. Transports discharged patient charts to HIM.
12. List new admissions/discharges and changes on the diet sheet.
13. Maintains adequate stock of supplies and forms.
14. Assist physicians as needed and within the scope of responsibility.
15. Greets patients and visitors.
16. Communicates reports, new orders, and messages to appropriate team members.
17. Secures needed services as directed by the Nurse Manager.
18. Assists with room assignments.
19. Maintains the Nurses’ Station in a neat, orderly manner.
20. Participates in continuing education, participates on committees as assigned.
21. Performs other duties as assigned, needed, requested, or required.

CONDITIONS OF EMPLOYMENT

• All information is subject to verification. False answers or omissions of information on application materials or inability to meet conditions of employment may be grounds for withdrawal of an offer of employment, or dismissal after being employed.
• All Employees are to be COVID-19 Vaccinated or approved for a Religious or Health Exemption.
• All employees must be screened daily at COVID-19 screening stations (ER entrance and Therapy entrance) prior to the start of shift and comply with mandatory face masking.
• All employees are required to successfully complete criminal background check and or fingerprint background check if applicable for the position.
• All employees must possess and maintain a valid and active incumbent Georgia Licensure and or certification based on Job description eligibility requirements.
• All employees must comply with EHS drug-free workplace policy and successfully pass pre-employment and post-employment drug screening requirements.
• All employees must wear proper PPE based on their designated Job Title:
• Materials Management, Environmental Services, and Maintenance staff must wear back brace while lifting anything 25 pounds or higher.
• Care Center direct resident care staff must wear back brace and gait belt at all times while on duty.
• Clinical staff are required to wear proper PPE designated to their function and duties.
• All employees are required to identify a financial institution for direct deposit of pay before the start of employment and during employment tenure.

Requirements

Minimum Level of Education: Education level equivalent to a high school diploma.

Formal Training: Management skills with experience in planning, organizing, implementing, facilitating, interviewing, counseling, and verbal and written communications.  

Licensure, Certification, Registration: None, Certified Nursing Assistant preferred.

Work Experience: One year of experience as a ward clerk, unit clerk, or medical office secretary is preferred.