Unit Ward Clerk

Essential Job Functions

• Assist in organizing, planning & directing the medical records section in accordance with established policies and procedures.
• Maintain a working rapport with other departments in the facility to assure that medical records can be properly maintained.
• Absorb all incidents/accidents and record them.
• File in accordance with established policies and procedures.
• Collect, assemble, check, and file resident charts and personnel records as required.
• Ensure incomplete records/charts are returned to nursing service for correction.
• Absorb in developing procedures to ensure records are properly completed, coded, signed, indexed, etc., before filing.
• Establish a procedure to ensure charts/records do not leave the section except as authorized in our policies and procedures.
• Maintain records of information taken from charts/records, i.e., type information, name of recipient, date, department, etc.
• Abstract information from records as authorized/required for insurance companies, Medicare, Medicaid, VA, etc.
• Maintain various registries as directed including register for admission and discharge of residents.
• Collect charts, assemble them in proper order, and inspect them for completion.
• Perform miscellaneous duties pertaining to medical records and assist business office personnel as required/directed.
• Absorb in admission, transfer and discharge procedures as necessary.
• Answer telephone inquiries concerning medical records functions.
• Prepare written correspondence as necessary.
• Retrieve medical records when requested by authorized personnel (i.e., physicians, nurses, government agencies, etc.).
• Absorb in assuring that medical records taken from the department are signed out and signed in upon return to the department.
• File active and inactive records in accordance with established policies.
• Index medical records as directed.

Qualifications

• Must possess, as a minimum, a high school diploma or equivalent.
• Must have knowledge of medical terminology.
• Must possess a current, unencumbered, active CNA license in this state.
• Must be able to read, write, speak, and understand the English language.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.
• Must possess the ability to plan, organize, develop, implement, & interpret programs, goals, objectives, policies & procedures, etc., that are necessary for providing quality care.
• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.