Unit Clerk
Position Summary:
Performs a variety of clerical duties, which provide support to nursing staff, physicians and other members of the patient care units.
Essential Functions:
- Patient Record Management
- Prepares, maintains, and processes medical record throughout patient's hospitalization.
- Assures timely data entry and accuracy of information.
- Sets up and breaks down patient charts. Completes chart abstracts/prepares and copies medical record for intra and inter-hospital transfers.
- Works directly with the Nurse Manager/designee to maintain medical records during internal and external disasters.
- Maintains manual backup system for transcription of physician's orders during computer downtimes.
- Prints order forms and labels as requested.
- Files test results, transcribed notes, and procedure reports in medical record.
- Maintains, assembles, copies, prepares, and sends patient charts to medical records within 12 hours of discharge.
- Makes ID bracelet, compiles patient medical record, and notifies Social Worker in order to complete admission, registration, and transfer of patients.
- Routinely checks each medical record for proper order. Routinely checks and removes excess labels and forms from chart.
- Maintains log book.
- Enters data into computer for pre-registered, direct admit and intra-hospital transfer patients; prints/completes and obtains appropriate signatures on forms.
- Determines need for and orders food tray for late admissions and delayed meals, orders dietary changes and supplemental diets.
- Operates manual and automated data systems and equipment to order laboratory tests, x-ray examinations, pharmacy and other hospital services. Sends requisitions to schedule tests.
- Maintains an effective and efficient flow of information by responding to customer requests and through coordination of interdepartmental communications.
- Practices courteous telephone etiquette by identifying self and department when answering or placing calls.
- Answers phone, receives and conveys messages, routes and handles call within scope of authority.
- Answers patient call system promptly, decides priority for responses, notifies appropriate personnel and follows up to ensure delivery of service.
- Reads memos, emails and communication books.
- Communicates to staff, families, physicians and visitors in a clear concise manner.
- Orients new employees as assigned.
Qualifications/Requirements
- Entry level knowledge; basic employment skills; High School diploma: GED equivalent or High School certificate
- Experience: 1-3 years
- Medical terminology certificate preferred