GraftonCounty
Position Description

Position Title:Unit SecretaryDepartment:Nursing Home

Reports To:Health Information ManagerDate:June, 2014

Revised:June, 2014

GENERAL SUMMARY:

Under the supervision of the Health Information Manager, responsible for providing clerical support and organization on the Nursing Unit.

ESSENTIAL JOB FUNCTIONS:*

  • Maintains the resident medical charts in an organized and orderly condition; adds new forms, files, and thins charts, as needed; flags charts for physician and nurse practitioner signatures.
  • Notifies Medical Transcriptionist regarding admissions, discharges, deaths, room changes and floor transfers.
  • Ensures resident paperwork is copied and ready for scheduled appointments.
  • Transcribes resident information (TPR, BP, weights) into the medical record and into the computer.
  • Answers the telephone on the unit; greets visitors and directs them to appropriate locations; assists in delivery of mail, flowers, newspapers, and items in need of repair.
  • Keeps medical forms and clerical supplies on the unit stocked and organized.
  • Maintains the nurses station in an organized and tidy manner.
  • Responsible for updating report sheets, daily assignments, shaver lists, BP and weights, and meal percentages.
  • Photocopies forms.
  • In absence of Health Information Manager, abstracts information from records, as authorized, for release of information.
  • Sends department related facsimiles to appropriate locations as directed. Makes photocopies as needed.
  • Ensures resident chart labels are up-to-date and accurate.
  • Maintains resident Care Plan books.
  • Maintains information in the archives after thinning of charts.
  • Maintains confidentiality of all resident records to assure resident rights are protected.
  • Assists Health Information Manager with projects.

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Unit Secretary

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ESSENTIAL JOB FUNCTIONS:* (continued…)

  • Inputs resident information into computer on admission to the unit for Nursing/LNA assignments
  • Helps the Health Information Manager with the admission of a new resident to the facility.
  • Takes resident’s picture upon admissions and inputs into the computer.
  • Inputs Lab Requisitions into the computer and prints when complete on a daily basis as needed.
  • Keeps the Lab books on the unit up to standards.
  • Abstracts and completes D/C charts. Notes Physician/Nursing for any missing information, signature/DC summary.

OTHER DUTIES AND RESPONSIBILITIES:

  • Assures that Medical Records taken from the Unit are signed out and signed in upon return to unit.
  • Pulls charts, files care plans when meetings are complete,
  • Promotes and maintains responsive community relations.
  • Overtime may be mandated, as necessary, at the discretion of management.
  • Submits to a TB skin test as required, unless exempted by the Employee Health Nurse.
  • Attends all mandatory in-services.
  • Reports any workplace safety concerns to Supervisor immediately.
  • Performs other related duties as required.
  • Scanning of discontinued records into computer.
  • Maintains the confidentiality of all residents and facility information, and ensures information is not released without proper authorization.

SKILLS/EXPERIENCE/TRAINING REQUIRED:

Duties require knowledge of medical records equivalent to completion of high school diploma and six months to one year of related experience, or equivalent combination of education and experience.

Knowledge of modern office practices, procedures, and equipment.

Ability to operate a wide variety of office equipment including computers, photocopy machines, and facsimile machines.

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Unit Secretary

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SKILLS/EXPERIENCE/TRAINING REQUIRED(continued):

Skill in alphabetizing and putting patient charts in correct order.

Knowledge of computer software programs used for medical record tracking.

Knowledge of medical terminology.

Ability to communicate effectively both verbally and in writing and to establish effective working relationships with other office personnel.

Ability to maintain confidentiality of sensitive information.

Ability to handle multiple tasks and adapt quickly to changing priorities.

Organizational and customer service skills.

SUPERVISORY RESPONSIBILITY:

This job has no supervisory responsibilities.

WORKING CONDITIONS/PHYSICAL DEMANDS:

Normal office environment, not subject to extremes in temperature, noise, odors, etc.

Regularly uses computer keyboards requiring eye/hand coordination and finger dexterity.

May require some lifting of resident charts and records.

More than half of time spent in normal office setting.

The above statements are intended to describe the general nature and level of work being performed by people assigned to do this job. The above is not intended to be an exhaustive list of all responsibilities and duties required.

*External and internal applicants, as well as position incumbents who become disabled as defined under the Americans With Disabilities Act, must be able to perform the essential job functions (as listed) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.

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ApprovalDate

I have read this position description and understand its content.

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Employee SignatureDate

06/14