Medical Records ~ Unit Secretary

Job Description: 

Summary

The Unit Secretary serves as a clerical support role in the Care Center, assisting in the coordination of neighborhood activities including admissions and discharges and order entry. 

Responsibilities

1. Greets residents and visitors at the desk in a friendly, courteous manner; Presents a positive image at all times while directing residents, visitors and staff to appropriate areas; Makes all residents and visitors feel welcome and cared for

2. Works closely with health services counselor to ensure coordination of admission of residents; Completes proper admission documents; Assists nurse with room assignments and assist in room set up as needed; Ensures that each new resident has an admission bag/packet in room prior to their arrival

3. Coordinates discharge/transfer of resident; Prepares documents as needed for discharge; Ensures all paper documents are placed in clinical record and that it is sent to Health Information Coordinator following discharge of resident

4. Answers telephone efficiently and courteously; relays messages and calls to appropriate personnel and residents; relays information to other departments as needed

5. Assists nursing staff with supply management including obtaining needed equipment or supplies from Central Supply and running supply management reports as needed

6. Maintains clinical records in an orderly manner; Keeps charts supplied with needed forms; Makes sure all forms are identified with resident name; Obtains past medical records form Health Information department under direction of the nurse; Operates copy machine

7. Assures recording of resident information in clinical record; Posts lab and x-ray results; Posts signed physician orders; Notifies charge nurse when information is missing

8. Makes appointments for residents (outside medical and dental visits), and assists in the coordination of transportation to the appointments; Notes appointments per community practice (i.e. on shared calendar)

9. Assists physician as needed by gathering paperwork, reports and needed supplies

10. Obtains routine reports from EMR as defined by Clinical Nurse leader (i.e. residents without pictures, weight report)

11. May be assigned the responsibility of transcribing physician orders into EMR; Preparing requisitions (electronic or paper) for diagnostic studies as needed; Assuring timely completion of stat orders; Notifying the nurse of new orders and assuring orders are double checked for transcription by the nurse; Referring telephone and verbal orders to RN/LPN; Notifying nurse of any stat treatments or medication; Noting initials, date and time on orders transcribed

12. Assists Nursing Leadership as needed

13. Answers call lights if needed, assisting resident as able and notifying appropriate staff of resident need

14. Provides assistance to other Care Center neighborhoods as needed

Qualifications, Knowledge, Skills & Abilities

• High school diploma or equivalent

• Training in secretarial/administrative skills and medical terminology essentials preferred

• Prior experience as a “Unit Secretary highly preferred. Certification as a nursing assistant or medication technician (CNA/CMT) desirable

• Must be an individual who enjoys working in a busy, fast paced setting

• Strong verbal and written communication skills

• Must be able to maintain a high degree of accuracy under stress,

• Complete detailed work without error and handle several tasks at once

Physical Requirements and Working Conditions

Works in clean, well-lighted, heated and air-conditioned area. Exposure to unpleasant sights and smells possible. Moderately low risk for exposure to infectious diseases. Will work in crowded, noisy environment most of the time. Exposure to unpleasant sights, smells and infectious diseases possible. Meal and coffee breaks may be delayed and interrupted at times. May be required to sit for long periods of time. Normal speech, vision, hearing are necessary. Must be physically able to operate telephone, copy machine and handle medical records and other documents. May be asked to assist with direct patient care duties at times.

This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position.  Employees may be required to follow other job-related instructions and to perform other job-related duties as requested, subject to all applicable federal, state, and local laws and standards. Certain job functions described herein may be subject to possible modification in accordance with applicable federal, state, and local laws and standards.

Additional Information:

N/A