Unit Secretary-Medical Surgical, Stroke Unit

About the Role

Responsible for viewing and processing physician orders in the electronic medical record, transcribing physician orders when needed (especially during downtime procedures), maintaining bed management records, accessing lab results, performing receptionist and clerical duties, and coordinating non-nursing services within the unit.

Responsibilities

• Initiate, assemble, and maintain accurate, functional medical records for all patients in the assigned unit.
• Accurately view and process physician orders in the electronic medical record.
• Accurately 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 through to obtain missing information.
• Maintain a proper inventory supply of paper forms to provide continuous service, minimize downtime, and ensure a safe, clean, and functional working environment in the nursing station and nursing area.
• Update all unit forms and manage their storage.
• Courteously greet and assist visitors, screen telephone calls, and answer call buttons via the nurse’s station intercom or in person in patient rooms, directing to the appropriate caregiver.
• Process mail and other correspondence.
• Make phone calls to relay patient information and schedule appointments as directed.
• Answer inquiries on procedures and policies relating to departmental functions.
• Prepare medical records upon patient discharge.
• Copy medical records and obtain necessary discs for patient transfers/discharges to other facilities.
• Accurately maintain patient census management manually and electronically.
• Assist with accessing or retrieving reports as requested.
• File documents following standard procedures; maintain medical records in a neat and orderly manner.
• Attend daily Interdisciplinary Discharge Rounds and keep a log of potential discharges for that day or the next day.
• Obtain the Advanced Directive List and Discharge Flag Report from the unit’s printer for shift-to-shift safety huddles daily.
• Obtain the overdue lab specimen report from the unit’s printer for distribution to the unit’s RN and CNA staff daily.
• Hourly floating as necessary to fill in for open unit secretary areas throughout the inpatient units.
• Print lab slips as necessary, especially during downtime procedures.
• Order, track, and file equipment (Wound VACs, specialty beds/mattresses) paperwork as applicable.
• Orient new staff members into the role of unit secretary, covering all job responsibilities as indicated in this description.
• Communicate pertinent patient care information and general information to the appropriate nursing staff.
• Perform all other related duties as assigned.

Requirements

• High School diploma and a minimum of one year of job-related experience or equivalent.
• Basic computer skills and medical terminology.

About Us

Care New England Health System (CNE) and its member institutions—Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group—is a trusted, integrated health care organization that fuels the latest advances in medical research, attracts top specialty-trained doctors, hones renowned services and innovative programs, and engages in important discussions about health and end-of-life wishes. Care New England is helping to transform the future of health care, providing a leading voice in efforts to ensure the health of the individuals and communities we serve.