PURPOSE OF YOUR POSITION
The primary purpose of your job position is to assist the Charge and Staff 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 all medical records are maintained in an informative and descriptive manner.
High School graduate preferred.
MAJOR DUTIES AND RESPONSIBILITIES
- Meet the clerical needs of nursing units, including organization and maintenance of medical records on nursing units.
- Book M.D. appointments, x-rays, transportation, etc., when directed by Charge Nurse.
- Maintain and document as necessary, in unit books, i.e., lab books, doctor’s memo book, unit calendars.
- Thin medical records, replace forms systematically, pull medication kardex after the fifth of the month and maintain chart order.
- File and order paper supplies as needed.
- Maintain up-to-date list of residents orders due and notify DNS/ADNS on late doctors.
- Monitor annual lab tracking and records.
- Complete admission chart audits and audit mechanics of medical record.
- Complete and deliver to appropriate departments, all forms regarding residents, i.e., diet slips, transfer forms, starts information for W-10s.
- of medical terminology, filing, typing and organizational skills.
Please contact firstname.lastname@example.org for more information.