Unit Secretary & Medical Records Clerk

Capital Health Screening Centre; Pennington (NJ); On-site; USD 23,000 - 28,000; Full time

Benefits offered by this job

Retirement Savings and Investment Plan

Disability Benefits – Short Term (STD)

Sick Time Off

Employee Assistance Program

Job summary

Capital Health is seeking a unit clerk/medical records assistant to transcribe physicians' orders accurately, maintain MAR, Kardex, nursing flowsheets, and manage patient charts. The role includes creating, updating and filing patient records, coordinating with departments, scheduling tests, handling calls, ensuring confidentiality, and supporting patient flow.

Requires a high school diploma, 1 year of experience or training, knowledge of medical terminology and transcription skills.

Qualifications

• Education: High school diploma or GED.
• Experience: One year of experience or training in a secretarial role or currently enrolled in an accredited nursing school or medical professional healthcare program.
• Knowledge and Skills: English speaking skills. Basic organizational and reception skills.
• Special Training: Knowledge of medical terminology. Transcription skills.
• Mental, Behavioral and Emotional Abilities: Customer focused.
• Usual Work Day: 8 Hours

Responsibilities

• Transcribes physicians' orders accurately and in a timely manner.
• Generates and maintains tools necessary for patient care (Kardex, MAR, Nursing Flowsheets, and other treatment sheets).
• Creates, maintains, and terminates patient charts in compliance with Medical Records guidelines.
• Obtains and files test results, lab reports, and treatments in charts.
• Ensures the integrity of the medical record, including patient identification on all chart forms.
• Maintains chart forms in correct placement in the chart behind the correct chart tab.
• Guarantees that all chart documents are placed in the chart in preparation for transfer or discharge.
• Returns old records to medical record department upon discharge.
• Sends thinned charts to new unit upon transfer or discharge.
• Maintains patient census and status boards, log books, and computer databases, ensuring that date and records are current and accurate.
• Copies records and other information as needed.
• Ensures unit is appropriately supplied with the necessary forms and supplies on order for unit to run smoothly.
• Expedites the delivery of materials and supplies by preparing orders, tracking the processing of paperwork, and following up with the appropriate parties on a timely basis.
• Prepares unit charges as appropriate for specific unit needs.
• Performs other duties as assigned; willingness to adapt to changing department demands.
• Answers and places telephone calls timely.
• Takes accurate and complete messages.
• Pages personnel, other departments, and physicians, as needed on a timely basis.
• Facilitates the movement of patients into and out of the unit and keeps the Charge nurse informed of patients to be discharged or transferred.
• Coordinates with patient transport and admission personnel regarding admissions and transfers as needed.
• Provides non-clinical information (e.g. directions to a department, location of a patient's room, identification of assigned nurse) to patients, family members, visitors, staff and physicians.
• Monitors communication in the nursing station to protect patient confidentiality.
• Schedules timely diagnostic tests and lab work as prescribed by nursing and medical staff.
• Assists in answering call bells and communicating specific patient needs to staff efficiently.
• Handles medication deliveries from Pharmacy and places medications in appropriate medication storage area.

Skills

English speaking skills

Medical terminology

Transcription skills

Education

High school diploma or GED

Job description

Capital Health is seeking a unit clerk/medical records assistant to transcribe physicians' orders accurately, maintain MAR, Kardex, nursing flowsheets, and manage patient charts. The role includes creating, updating and filing patient records, coordinating with departments, scheduling tests, handling calls, ensuring confidentiality, and supporting patient flow.

Requires a high school diploma, 1 year of experience or training, knowledge of medical terminology and transcription skills.