Job Responsibilities
1. Initiate, assemble, and maintain accurate, functional medical records for all patients in the assigned unit. View and process physician orders in the electronic medical record. 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 up to obtain missing information.
2. Maintain inventory of paper forms needed for continuous service, minimizing downtime, and ensuring a safe, clean, and functional working environment in the nursing station and area. Update and manage storage of all unit forms.
3. Greet and assist visitors courteously, screen calls, and respond to call buttons via nurse station intercom or in person. Process mail, relay patient information, schedule appointments, and answer inquiries related to departmental procedures and policies.
4. Prepare medical records upon patient discharge, copy records, and obtain necessary discs for transfers or discharges.
5. Maintain patient census both manually and electronically. Assist in accessing or retrieving reports as requested. File documents following standard procedures, ensuring records are neat and orderly.
6. Participate in daily interdisciplinary discharge rounds and keep logs of potential discharges. Obtain and distribute reports such as the Advanced Directive List, Discharge Flag Report, and overdue lab specimen report daily.
7. Provide hourly coverage as needed across inpatient units to fill in for open secretarial areas. Print lab slips during downtime procedures.
8. Order, track, and file equipment paperwork (e.g., Wound VACs, specialty beds/mattresses). Orient new staff members to all responsibilities of the unit secretary role.
9. Communicate pertinent patient care and general information to nursing staff. Perform other related duties as assigned.
Qualifications and Requirements
High School diploma and at least one year of relevant experience or equivalent. Basic computer skills and knowledge of medical terminology are required.
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