Temporary Ward Clerk, Data Entry Specialist

This is a Temporary Full-Time position

In order to fulfill the job functions listed below an individual must meet the following minimum qualifications.

Communicate effectively in person on the telephone and in writing.

Possess a High School diploma or equivalent.

*Proficiency in computers including current Charting Software and Outlook-365 Encryption

*Possess computer word processing skills.

*One year experience in medical terminology medications (understanding basics of Pharmacology) transcription computer data entry filing sorting and record keeping (Preferred).

Minimum of one year experience in the medical record field (Preferred).

*These qualifications will be skill tested. Minimum requirements must be demonstrated to be awarded the positions.

REQUIREMENTS

Comply with all Facility policies and procedures.

Comply with all policies and procedures as may be established by your director.

Comply with all safety universal precautions and infection control policies and procedures.

Present a friendly calm cooperative positive manner.

ESSENTIAL JOB FUNCTIONS

On occasion may need to lift up to 40 lbs.

Prompt and regular attendance.

Assist nurses to proofread physicians orders; carry out physicians orders and check for signatures; make copies

for pharmacy and deal directly with Pharmacy.

Update orders in nursing computer; update and proofread resident medication administration records (MAR)

and treatment administration records (TAR).

Update diets and check for accuracy.

Assist with in-house resident transfers notifying all departments and changing records as appropriate.

Assist with admissions and with emergency transfers to ER.

Prepare appropriate forms for resident admission and discharge; assure all required information is included in

chart from the admission checklist; assemble admission record and record information. Prepare orders for

signature via encrypted Outlook-365 email to remote Physician practices.

Prepare orders for signature via encrypted Outlook-365 email to remote Physician practices.

Schedule resident appointments outside the Facility; prepare appropriate paperwork to accompany to resident

coordinated transportation for appointment.

Schedule labs; complete lab slips for local hospital prepare lab list for upcoming lab day and call in or fax to local

hospital; prepare x-ray requests forms for portable unit and notify hospital.

Verify all code status and allergies to assure they are accurately posted in residents chart. Room wristband and

computer.

Prepare name bands for residents place ID tags on chart place allergy tags on chart; place O2 signs; replace IDs as necessary.

Fax messages to physicians and fax medication list to pharmacy

Transcribe physician dictation to include residents history and physical discharge summary progress notes

care plans; transcribe other correspondence/reports.

Chart monthly TPRs weights in resident charts and MD progress notes.

Check labs to be performed every two months via computer and index card.

Prepare new forms for the month including Physicians order MARs and TARs.

Assist residents returning from appointments; review orders received.

Return completed charts to Medical Record Department.

Maintain and control release of information of medical records per procedure.

File all lab reports & x-rays on charts; make copies of faxed able results and file in charts & scan to computer.

Update I & O BM list feeding list and 24-Hour Report weekly.

Prepare new vital signs sheet weight sheet and O2 log sheet.

Check flow sheets for blank spaces and signatures; replace new flow sheets and folders as necessary.

Review contents of medical record and purge according to procedure.

Take accurate telephone messages for supervisors and residents.

Assist residents as needed when making personal telephone calls.

Assure adequate supply of forms and supplies are in desks and drawers.

Place blank physicians orders and nursing notes in charts as needed.

Purge archives of records to be destroyed.

Shred confidential material as needed.

Maintain confidentiality.

Requisition supplies as needed.

Maintain clean orderly and safe work environment.

Immediately report malfunctioning or unsafe or suspected malfunctioning or unsafe equipment or conditions

to supervisor.

Attend required in-services and required meetings.

Other duties may be assigned.

Required Experience:

Junior IC