Overview
Responsible for viewing and processing physician orders in the electronic medical record, transcribing physician orders when needed especially during downtime procedures, maintaining bed management records, accessing lab results on the computer, performing receptionist and clerical duties, and coordinating non-nursing services within the unit.
Responsibilities
* Initiate, assemble and maintain accurate, functional medical records for all patients in the assigned unit. Accurately view and process physician orders in the electronic medical record. Accurately transcribe written physician orders when needed, especially during downtime procedures, and complete all necessary forms, requisitions and communications to implement orders and record clinical data. Follow through to obtain missing information.
* Maintain a proper inventory of paper forms needed to provide continuous service, minimize downtime, and keep the nursing station and nursing area safe, clean and functional. Responsible for updates to unit forms and managing their storage.
* Courtiously greet and assist visitors, screen telephone calls, and answer call buttons through the nurse’s station intercom or in person in the patient’s room as applicable. Direct to the appropriate caregiver. Process mail and other correspondence. Make phone calls to relay patient information and schedule appointments as directed. Answer inquiries on procedures and policies relating to departmental functions.
* Prepare medical records upon discharge of patients.
* Copy medical records and obtain necessary discs for patient transfers and discharges to other facilities.
* Accurately maintain patient census management manually and electronically.
* Assist with accessing or retrieving reports as requested.
* File documents following standard procedures; maintain medical records in a neat and orderly manner.
* Attend daily Interdisciplinary Discharge Rounds and keep the log of potential discharges for the day or the next day.
* Obtain the Advanced Directive List and Discharge Flag Report from the unit printer for shift-to-shift safety huddles daily.
* Obtain the overdue lab specimen report from the unit printer for distribution to the unit’s RN and CNA staff daily.
* Hourly floating as necessary to fill in for open unit secretary areas throughout the inpatient units.
* Print lab slips as necessary, especially during downtime procedures.
* Order, keep track of, and file equipment paperwork (Wound VACs; specialty beds/mattresses) as applicable.
* Orient new staff members into the role of unit secretary and to all job responsibilities described in the description.
* Communicate pertinent patient care information and general information to the appropriate nursing staff.
* Perform all other related duties as assigned.
Job Qualifications and Requirements
High School diploma and a minimum of one year job-related experience or equivalent are required. Basic computer skills and medical terminology are also required.
Care New England Health System
Care New England Health System (CNE) and its member institutions Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, Care New England Medical Group, and our Wellness Center are trusted organizations fueling the latest advances in medical research, attracting the nation’s top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.
Americans with Disability Act Statement
External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.
EEOC Statement
Care New England is an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.
Ethics Statement
Employee conducts themselves consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.
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