Under general supervision and according to established policies and procedures, provides clerical support for assigned Medical Surgical Unit. Transcribes physician’s orders, schedules diagnostic tests and therapies. Maintains strict HIPPA standards for confidentiality for all forms of communication. Assembles and maintains medical records. Answers telephones and intercom calls, relays calls and messages. Assists Unit Manager in clerical functions essential to day-to-day operations of the patient care unit.
Management of Information
- _____Demonstrates proficiency of policies and procedures related to patient medical records.
- Adheres to KCH IS Security and HIPAA policies. Will hold in confidence any and all patient information communicated or stored using any medium including oral communication. The associate will seek to protect patient information from inadvertent use or disclosure by adhering to hospital and Triad Blue Book policies.
- Assembles appropriate patient charts for newly-admitted inpatient and observation patients and maintains current charts by filling physician orders, progress notes, nurses notes, etc.
- Completes identification of chart.
- Demonstrates correct selection of forms for completion for procedures, transfers, discharges, etc
- Initials form prior to placing results in chart to demonstrate accountability for accuracy.
- Disassembles and routes patient charts to appropriate department upon discharge, transfer, expiration or as requested.
- Contributes to record completeness by auditing and flagging charts for signatures.
2._____ Demonstrates consistency of knowledge of policies and procedures related to order transcription.
- Demonstrates ability to accurately interpret written order and will clarify with nurse and physician when indicated to assure clarity of intent of the order.
- Notifies nursing personnel of orders requiring immediate attention.
- Demonstrates appropriate use of STAT, NOW, and RESULTS BY order entry.
- Follows through with completing the "critical lab results" form and reporting to appropriate nurse.
- Demonstrates proficiency with assigning standard medication administration schedules on appropriate records.
- Keeps current with changes in order entry requirements for laboratory and radiology tests.
- Transcribes prep orders for required tests
3._____ Demonstrates proficiency with computer entries and “down time procedures” for all aspects of clerical support of patient care.
- Maintains computer competency annually.
- Demonstrates timely order entry and proficiency meeting unit standards for accuracy.
- Includes specific patient information within order entry process to facilitate timely, accurate, cost effective patient care.
- Consistently prints “parent” orders to facilitate quality check for accuracy of order entry.
4.____Demonstrates proficiency in assuring patient identification and security system activation.
- Demonstrates competency in use of all ID bands and monitoring
- Correctly prepares proper ID for parents and/or guardian of minors.
- Monitors child abduction monitor.
- Monitors for battery problems and lead failure on telemetry monitors.
Communication with Health Care Team
5._____Demonstrates proficiency in facilitating timely communication linkages between health care team members to assure quality patient care.
- Documents and completes consult logbook.
- Demonstrates proficiency with obtaining and printing physician credentials.
- Completes physician-consulted identification of chart with appropriately colored tape.
- Maintains patient room identification board, and updates physician/patient identification binder.
- Notifies department of consults such as dietary, physical therapy, speech therapy, and occupational therapy, pharmacist, etc by computer entry as well as by a logged telephone call.
- Notifies registration of patient room changes in a timely manner.
- Assures printed reports are promptly placed on the patient’s medical record for immediate reference by the health care team.
- Assures lab specimens are delivered promptly to the laboratory for processing
- ____Demonstrates proficiency with use of various electronic communication methods to support patient care. Minimizes batch paging on patient intercom striving to provide a quiet environment while expediting communications.
- Demonstrates customer service standards for telephone etiquette.
- Sends and receives fax communication between departments and health care providers.
- Maximizes use of portable telephone system.
- Demonstrates proficiency in paging physicians, etc.
- ___Relays information to other hospital departments to facilitate timely room turnover, and maintenance of facility.
- Notifies housekeeping of patient discharges.
- Notifies plant operations of need for equipment and or facility maintenance or repair.
- Notifies Biomed of electronic equipment repair needs.
8.____Inventories and creates supply requisitions to support clerical and patient care needs.
- Demonstrates proficiency with barcode system to assure charges are assigned.
- Monitors and assures appropriate levels of supplies are available for patient care to include clerical record supplies.
Communication with Patients/Visitors
- ____ Demonstrates excellent communication skills, maintaining a calm reassuring demeanor at all times.
- Participates in the Customer Satisfaction program and utilizes service recovery tools when indicated.
- Greets and directs patients and visitors
- Responds verbally to patient intercom calls and promptly directs appropriate caregiver to a speedy response.
- May respond personally to bedside assistance calls.
- _____Demonstrates skills associated with direct patient care to include assistance with activities of daily living and emergency care.
- CPR certified with AED
- Maintains competencies in obtaining and recording vital signs
- Fit tested for level C mask and demonstrates ability to don and doff level c wear.
- Demonstrates age appropriate competency skills and knowledge, displays ability to perform skills specific to patient population identified in unit specific skill list:
_____Infant _____child _____adolescent _____adult _____geriatric
(Mark age specific of patients served in alternative units assigned)
_____Infant _____child _____adolescent _____adult _____geriatric
- Assist with census balancing, and observation charts as directed by the Unit Manager or Shift Leader.
- May be reassigned to other units to facilitate patient care.
Performs other duties as assigned.
Education and Formal Training Required:
High school graduate or the equivalent.
Must have basic PC skills including: word processing and following menu driven training programs.
Ability to type 45 wpm with a 95 % accuracy rate.
Excellent verbal and written communications skills in order to interact with people effectively; ability to interpret a variety of documents and correspondence relating to patient medical records.
Prior experience using a computer/keyboard to analyze data.