Nspire Healthcare Unit Clerk in Cape Coral, Florida
Job Category (Icims Portal - Choose 1) Admin - Clerical
Position Location : Location US-FL-Cape Coral
Care Center Coral Trace Health Care
Position Location : Street 216 Santa Barbara Boulevard
Position Location : Zip 33991-2031
Position Status FT is 35+ HOURS WK
HERE TO NSPIRE CHANGE
Purpose of Your Job Position
The primary purpose of your job 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, to ensure that our medical records are maintained in an informative and descriptive manner. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results.
As Unit Clerk, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. The primary purpose of your job 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. No supervisory responsibilities.
Record medical and administrative information in accordance with established charting and documentation policies and procedures.
Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.
Maintain an up-to-date roster of residents for your assigned unit.
Answer telephone, page calls; deliver messages to residents, etc., as necessary.
Maintain a current listing of emergency phone numbers for your assigned unit.
Maintain and forward daily tardy and absentee reports to the Business Office.
Record appropriate resident identification data on designated medical records, wristbands, ID cards, etc., as required.
Transcribe physicians’ orders to care plans, medication cards, treatment plans, etc., as required.
Record vital signs as directed.
Forward new diet orders and/or diet changes to the Director of Dining Services.
Keep nursing service personnel informed of residents’ appointments.
Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
Notify the resident’s responsible party when there is a change in the resident’s condition as instructed.
Admit, transfer, and discharge residents. Assist in arranging for transportation, packing residents’ belongings, escorting them to discharge/transfer area, loading, etc., as necessary.
Assist in the completion of necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
Forward completed charts of discharged residents to the Medical Records/Health Information Department.
Direct visitors to resident rooms, office areas, etc., as necessary.
Education and Experience
Must possess, as a minimum, a high school diploma.
Must have two (2) years experience in similar position.