Ward Clerk

About the Role

Assist the Nurse Supervisor/Charge Nurse in day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations to ensure medical records are maintained in an informative and descriptive manner.

Responsibilities

• Record medical and administrative information following established charting and documentation policies.
• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.
• Maintain an up-to-date roster of residents for your assigned unit.
• Fill out resident charge slips and submit to the Business Office.
• Answer telephone, page calls, and deliver messages to residents as necessary.
• Maintain a current listing of emergency phone numbers for your assigned unit.
• Maintain and forward daily tardy and absentee reports to the Business Office.
• Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc.
• Transcribe physicians’ orders to care plans, medication cards, treatment plans, etc.
• Report discrepancies in transcribing physicians’ orders, diet orders, or charting to the Nurse Supervisor/Charge Nurse.
• Review medication cards for completeness, accuracy, and legibility.
• Chart nurses’ notes in an informative and descriptive manner reflecting care provided and resident’s response.
• Forward new diet orders or changes to the Director of Food Services.
• Notify next-of-kin of changes in resident’s condition as instructed.
• Admit, transfer, and discharge residents, including arranging transportation and packing belongings.
• Complete necessary medical and administrative records upon resident admission, transfer, or discharge.
• Forward completed charts of discharged residents to the Medical Records/Health Information Department.
• Attend facility committee meetings (e.g., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment).
• Assist in developing work assignments and schedules.
• Develop and maintain good working rapport with inter-departmental personnel.
• Inform nursing service personnel of new admissions, room assignments, and expected arrival times.
• Greet newly admitted residents and escort them to their rooms.
• Encourage attending physicians to record and sign progress notes and orders timely.
• Inform family members of resident deaths as instructed and call funeral homes when requested.
• Attend annual facility in-service training programs (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control).
• Participate in training for tasks involving potential exposure to blood/body fluids.
• Participate in the infection control program for monitoring communicable diseases.
• Inform the Nurse Supervisor/Charge Nurse of equipment and supply needs.
• Ensure all personnel are aware of and follow the resident’s care plan.
• Report suspected or known incidence of fraud (e.g., false billings, kickbacks).
• Treat all residents with kindness, dignity, and respect.
• Assist in recording and filing all incidents/accidents per established policies.
• Agree not to disclose resident’s protected health information and report suspected violations.
• Perform other duties as assigned by the supervisor, Director of Nursing, or Administrator.

Requirements

• High school diploma or GED.
• Exceptional communication and customer service skills.
• Ability to read, analyze, and interpret professional journals, regulations, and technical procedures.
• Ability to write reports, business correspondence, and procedure manuals.
• Ability to effectively present information and respond to questions.
• Basic mathematical skills (fractions, percentages, ratios, proportions).
• Ability to solve practical problems with limited standardization.
• Ability to interpret instructions in written, oral, diagram, or schedule form.
• Basic knowledge of medical terminology and nursing practices is helpful.

Physical Demands

• Occasionally lift and/or move up to 25 pounds.
• Prolonged use of desktop or laptop computer.
• Regularly required to sit, stand, walk, talk, read, or hear.
• Frequent use of office equipment (copier, scanner, fax, telephone, calculator).
• May assist in evacuating residents during emergencies.

Work Environment

The work environment is typically low to moderate noise. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.