Ward Clerk – CNA Certificate Required

WARD CLERK
DEPARTMENT: NURSING
Starting rate: $22/hr

POSITION: 
The purpose of your position is to assist the Nurse Supervisor/Charge Nurse in their day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records, and as may be required by the Director of Nursing Services, to ensure that our medical records are maintained in an informative and descriptive manner.

REPORTING:
Responsible to the Director of Nursing.

FLSA STATUS: 
Non-Exempt

QUALIFICATIONS/REQUIREMENTS:

Education:  Sufficient education to demonstrate functional literacy

License:  CNA certificate

Work Experience:

• Skilled in following written and verbal directions. Experienced in effective interaction with individuals who are cognitively and/or physically impaired.

Language Skills:

• Must be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language.

Mathematical Skills:

• Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to perform these operations using units of weight measurement, and volume

Communication Skills:

• Must have exceptional communicaation and customer service skills, and be empathetic.
• Ability to effectively communicate with patients, families, responsible parties, staff and outside resources and agencies.

ESSENTIAL FUNCTIONS:

• Maintain an up-to-date roster of residents for your assigned unit.
• Answer telephones, direct calls, deliver messages to residents, etc.
• Maintain current listing of emergency phone numbers for your assigned unit.
• Maintain and forward daily tardy and absentee reports.
• Record appropriate resident identification data on designated medical records, wristbands.
• Forward new diet orders and/or diet changes to the Dietary Supervisor.
• Keep nursing service personnel informed of resident’s appointments.
• Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
• Assist in arranging for transportation.
• Complete necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
• Forward completed charts of discharged residents to the Medical Records Department.
• Order lab/xrays and call for results.
• Assist the Nurse Supervisor/Charge Nurse in developing work assignments, and schedules.
• Inform nursing service personnel of new admissions, their expected time of arrival, room assignments, etc.
• Assist as necessary in the orientation of newly assigned personnel to your unit.
• Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession.
• Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.
• Participate in all fire safety and disaster preparedness drills in a safe and professional manner.
• Follow infection control guidelines.
• Report all allegations of resident abuse and/or misappropriation of resident property.
• Comply with resident rights ensuring that all residents are treated fairly, with kindness, dignity, and respect.
• Must function as a team member and have flexibility.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Possess the ability to deal tactfully and harmoniously with personnel, residents and all visitors.
• Shows dependability by being punctual; maintains consistent attendance.
• Maintain the confidentiality of all resident care information.

ASSOCIATED FUNCTIONS:

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures.
• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.
• Record vital signs as directed.
• Transfer residents.
• Pack residents’ belongings.
• Escort residents to discharge/transfer area, loading, etc.
• Direct visitors to resident rooms, office areas, etc.
• Attend various committee meetings of the facility.
• Implement recommendations from established committees.
• Assist in the orientation of newly assigned personnel.
• Interpret department policies and procedures to personnel, residents, and visitors.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments in the facility.
• Greet newly admitted residents upon admission. Escort to room as necessary.
• Assist in escorting residents to/from activity and social functions.
• Encourage attending physicians to record and sign progress notes, physicians’ orders, etc. in accordance with current regulations.
• Report administrative problem areas to the Director. Assist in developing and implementing corrective action.
• Call funeral homes when requested by the family.
• Attend in-service training programs.
• Follow established safety regulations in the use of equipment and supplies.
• Assist in maintaining nursing service work areas in a clean and sanitary manner.
• Report hazardous conditions or equipment to the Nurse Supervisor/Charge Nurse.
• Inform the Nurse Supervisor/Charge Nurse of your equipment and supply needs.
• Follow established preventive maintenance procedures for maintaining your equipment and supplies.

PHYSICAL CAPACITIES:

• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must meet the general health requirements set forth by the policies of this facility which includes an annual TB screening and physical examination.
• Must be able to lift a minimum of 10 pounds.
• Must be able to lift up and over 50 pounds with assistance.
• Must be able to move intermittently during working hours.
• Must be able to stand and sit for extended periods of time.
• Must be able to bend, squat, push, stoop and pull as needed.
• Must be able to cope with the mental and emotional stress of the position.

ENVIRONMENTAL CONDITIONS:
Inside work, normal temperatures, some noise, occasional fumes/odors, chemical exposure and potential exposure to bloodborne pathogens.

This job cannot be performed without exposure to the stresses associated with an intimate, 24 hour skilled care environment that delivers care and services primarily to disabled and cognitively impaired residents in an aging population. Examples of these stresses include, but are not limited to: emergency health or safety response, weekend and holiday duty, unusual or impaired behavior by residents, family reactions to having a loved one in a nursing home, death and dying, oversight of state surveyors, ombudsmen and federal officials, presence of consultants and attorneys, and variable involvement of medical staff.

HIPAA is a law that must be followed by all healthcare personnel at every level. This position is a Mandated Reporter regarding the suspicion of elder abuse and may have access to Protected Health Information (PHI).