Unit Clerk/Medical Records

About the role

The Unit Clerk/Medical Records is responsible for performing a variety of clerical duties relating to the updating and organizing of information on the nursing units; coordinating work within the unit as well as with other units and departments; reporting pertinent information to the immediate supervisor; responding to inquiries and requests from staff personnel, guests, and families.

Essential Functions

• Records medical and administrative information in accordance with established charting and documentation policies and procedures.
• Establishes, develops, maintains, and updates the filing system for the unit.
• Retrives information from the files when needed.
• Answers the telephone in a professional manner; directs calls to appropriate individuals and/or takes messages.
• Transcribes physicians' orders to care plans, medication cards, treatment plans, etc as required.
• Charts nurses' notes in an informative and descriptive manner that reflects the care provided as well as the resident's response to the care.
• Forward new diet orders to the Dietary Director.
• Notifies the Guest's family or designated contact when there is a change in the resident's condition, as instructed.
• Aids other departments with obtaining needed documentation and signatures from Guests, appointed guardians, and family members.
• Aids with new admissions, room transfers, and discharges of Guests.
• Provides coverage for front desk and relieves receptionist for breaks.
• Types and designs general correspondence, memos, charts, tables, graphs, etc. Proofreads copy for spelling, grammar, and layout, making appropriate changes.
• Reports all hazardous conditions, damaged equipment, and supply issues to appropriate persons.
• Assures that established infection control and standard precaution practices are maintained at all times.
• Follows established safety precautions when performing tasks and using equipment and supplies.
• Maintains the comfort, privacy, and dignity of Guests and interacts with them in a manner that displays warmth, respect, and promotes a caring environment.
• Communicates and interacts effectively and tactfully with Guests, visitors, families, peers, and supervisors.
• Answers and responds to call lights promptly and courteously when working in Guest Care Areas.
• Attends and participates in departmental meetings and in-services as directed.

Qualifications

• Must have experience with PointClickCare (PCC).
• Minimum of 1 to 2 years managing medical records in a long-term care or healthcare setting (preferred).
• Familiarity with Electronic Medical Records (EMR) systems required.
• High school diploma or GED required; Associate's or Bachelor's degree in Health Information Management or related field preferred.
• Working knowledge of HIPAA and state/federal documentation regulations.
• Strong attention to detail and organizational skills.
• Ability to work independently and maintain confidentiality.