Unit Clerk

Responsibilities

• Maintain medical records in accordance with federal, state, and facility guidelines.
• Act as clerk on Nursing Units to assist with non-professional tasks and duties.
• Serve as custodian of medical records, including coding, auditing discharged records, and ensuring completion.
• Prepare and set up charts for new admissions and update information as needed.
• Delete forms when indicated and maintain residual files following chart audit/deletion policy.
• Ensure quality assurance of closed and open medical records.
• Log all admissions, discharges, and transfers of residents.
• Review monthly vital signs for completeness and document in charts.
• Collect, assemble, and inspect charts for proper order and completion.
• Retrieve medical records upon request.
• Monitor Treatment Administration Records, Psychotropic Medication Records, and Medication Administration Records monthly for completeness and file them.
• Identify missing signatures and contact appropriate staff to complete records.
• Verify correct name and room number on all sheets and add headings as necessary.
• Place appropriate stickers on charts (e.g., DNR, Allergies, Advance Directives).
• Arrange and maintain storage of supplies in a neat and orderly fashion on the unit.
• Keep stock forms well-supplied and organized alphabetically in drawers.
• Maintain an up-to-date CNA book.
• Pick up mail for both units.
• Order office supplies and maintain par levels.
• Answer unit phones, identify self, take accurate messages, and transcribe legibly.
• Cover for the nursing secretary at the front desk during lunch breaks.
• Cover for central supply/staffing coordinator during absences.
• Be available to unit managers as needed.
• Perform other duties as assigned by the Director of Medical Records.

Staff Development

• Attend and participate in in-service educational classes and on-the-job training programs as directed.
• Attend and participate in approved workshops and seminars.
• Create and maintain an atmosphere of warmth, personal interest, and positive emphasis, as well as a calm environment throughout the facility.
• Attend annual OSHA and CDC in-service training programs for hazard communication, TB management, and bloodborne pathogens standard.

Safety and Sanitation

• Follow all established safety procedures and precautions when operating office equipment.
• Report equipment malfunctions or breakdowns to your supervisor immediately.
• Follow established regulations for labels and MSDSs for hazardous chemicals.
• Adhere to ergonomics policies and procedures for lifting techniques, repetitive tasks, and use of safety equipment.
• Report all unsafe or hazardous conditions to your supervisor immediately.
• Perform other tasks to ensure the facility is maintained in a clean, safe, and sanitary manner.

Equipment and Supply Functions

• Ensure administrative supplies are replenished in work areas as necessary.
• Use office supplies efficiently to avoid waste.
• Request repairs for office equipment as needed.
• Maintain neat and clean work areas, covering office equipment before leaving for breaks or at the end of the day.

Requirements

• At least 1 year of experience as a Unit Clerk in a nursing facility.
• Knowledge of medical records and terminology.
• High school graduate with prior work experience demonstrating competence in variable job requirements.

Benefits

• Competitive pay rates.
• Healthcare benefits (medical, dental, and vision).
• Paid time off.