Responsible for the paper process of the patient's visit which includes responsibility of patient record and accurate transcription of physician orders and entry. Works closely with Patient Care Team to ensure high quality patient care and employs good guest relations.
Completion of medical terminology course; completion of unit secretary class at an accredited college,
Memorial Healthcare Center, or equivalent on-the-job experience; requires level of education necessary
to read and interpret physicians' orders and patient charts; and performs basic math skills. BLS
Heartsaver is required.
EXPERIENCE: Previous experience preferred, not required.
PRIMARY JOB RESPONSIBILITIES
1. Assigns appropriate rooms to all admits with the assistance of care team.
2. In conjunction with Registration staff, assures all appropriate forms are signed to include: consent for treatment and/or surgery, insurance forms, DPOA, consent to publish, and consent to release information to third party payers. Assures patients are given admission booklet, DPOA book, and any appropriate insurance notifications. Obtains guardianship papers for chart, when appropriate. Notifies case manager of absence of DPOA.
3. Assembles chart upon admission and daily restocks chart with appropriate chart forms.
4. Enters appropriate charges and all orders on computer. Assures that all requested orders are signed by physician and accurately transcribes medication orders to the M.A.R.
5. Alerts appropriate ancillary department of STAT orders.
6. Contacts physicians when requested.
7. Coordinates and answers calls to unit.
8. Greets visitors and provides needed assistance.
9. Prints medication sheets.
10. Enters miscellaneous changes and discharges into computer to include:
A. Doctor change
B. Demographic change
C. Room transfer
D. Change of status (example: observation admit change to full admit)
11. Assures charts are available and secured on unit.
12. Releases patient information as directed by the charge nurse. This would include copying charts for LTC units or other healthcare providers. Assisting case managers in faxing charts and bed availability requests.
13. Places typed and completed reports on incomplete chart.
14. Makes appropriate arrangements for transfers and contacts additional nursing staff if needed for transfer.
15. Arranges order for after care supplies and makes appointments for outpatient care after discharge which may include Home Health as directed by the charge nurse.
16. Processes all discharges and assembles charts in proper order.
17. Thins medical record chart and files all loose reports.
18. Demonstrates job related aspects of patient safety to assure a safe environment, safe and effective use of equipment and technology, and decreased risk of potential adverse patient occurrences.
19. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
20. Must be able to demonstrate the knowledge and skills necessary to provide assistance appropriate to the age of patients and families served on his/her assigned unit. Must demonstrate knowledge of the principles of growth and development over the life span.