ward clerk

Poway Healthcare Center; Poway (CA); On-site; USD 42,000 - 61,000; Full time

Job summary

Poway Healthcare Center is seeking a Medical Records Clerk to assist the Nurse Supervisor with recording and charting of medical and administrative information in compliance with current standards and regulations. You will maintain census data, resident rosters, and documentation accuracy across admissions, transfers, and discharges.

The role requires precise transcription, strong communication, and organizational skills, with duties including charting, audits, and coordinating with multiple

Qualifications

• Exceptional communication and customer service skills.
• Ability to read, analyze, and interpret general business materials.
• Ability to write reports, business correspondence, and procedures.
• Ability to present information clearly to managers and staff.
• Mathematical skills for fractions, percentages, and ratios.
• Ability to solve practical problems with varied instructions.

Responsibilities

• Record medical and administrative information per charting policies and procedures.
• Maintain the Daily Census Report and submit to the Nurse Supervisor/Charge Nurse.
• Maintain an up-to-date roster of residents for the assigned unit.
• Fill out resident charge slips and submit to the Business Office.
• Answer telephone, paging, and deliver messages to residents as needed.
• Maintain emergency contact listings for the unit.
• Forward daily tardy and absentee reports to the Business Office.
• Record resident identification data on medical records, wristbands, etc.
• Transcribe physicians' orders to care plans, medication cards, etc.
• Report transcription discrepancies to the Nurse Supervisor/Charge Nurse.
• Review medication cards for accuracy and legibility.
• Chart nurses' notes reflecting care provided and resident responses.
• Notify next-of-kin when a resident's condition changes.
• Admit, transfer, and discharge residents; assist with transportation and belongings.
• Complete medical and administrative records at admission/transfer/discharge.
• Forward completed charts to Health Information Department.
• Attend facility committee meetings as required.
• Assist in developing work assignments and schedules.
• Maintain good working rapport with inter-departmental staff.
• Inform nursing staff of new admissions and room assignments.
• Greet new admissions and escort to rooms as needed.
• Encourage physicians to record and sign progress notes and orders timely.
• Inform families of resident deaths as instructed.
• Call funeral homes when requested by family.
• Participate in annual in-service training programs (OSHA, HIPAA, etc.).
• Participate in training for procedures involving exposure to blood/body fluids.
• Assist with infection control program monitoring.
• Inform Nurse Supervisor of equipment and supply needs.
• Ensure staff refer to care plans before administering care.
• Report suspected fraud related to billing or cost reports, etc.
• Treat residents with fairness, kindness, dignity, and respect.
• Record all incidents/accidents as per policy.
• Do not disclose resident health information; report violations.

Skills

Communication

Customer service

Reading ability

Writing ability

Attention to detail

Education

High school diploma or GED

Job description

General Purpose

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 Services, to ensure that our medical records are maintained in an informative and descriptive manner.

Essential Duties

• Record medical and administrative information in accordance with our 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.
• Fill out resident charge slips and submit to the Business Office.
• 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.
• Report to the Nurse Supervisor/Charge Nurse discrepancies found in transcribing physicians' orders, diet orders/changes, charting, etc.
• Review medication cards for completeness of information, accuracy in the transcription of the physician's order, legibility, etc., as directed.
• Chart nurses' notes in an informative and descriptive manner that reflects the care provided as well as the resident's response to the care.
• Forward new diet orders and/or diet changes to the Director of Food Services.
• Notify the resident's next-of-kin 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.
• Complete 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.
• Attend various committee meetings of the facility (i.e., Infection Control, Policy Advisory, Pharmaceutical, Quality Assurance & Assessment, etc.) as required.
• Assist the Nurse Supervisor/Charge Nurse in developing work assignments, schedules, etc., as required.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility.
• Inform nursing service personnel of new admissions, their expected time of arrival, room assignment, etc.
• Greet newly admitted residents upon admission. Escort to room as necessary.
• Encourage attending physicians to record and sign progress notes, physicians' orders, etc., on a timely basis and in accordance with current regulations
• Inform family members of the death of a resident as instructed.
• Call funeral homes when requested by the family.
• Attend and participate in annual facility in-service training programs as scheduled (e.g., OSHA, TB, HIPAA, Abuse Prevention, Safety, Infection Control, etc.).
• Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.
• Participate in the implementation, and maintenance of the infection control program for monitoring communicable and/or infectious diseases, including TB, among the residents and personnel.
• Inform the Nurse Supervisor/Charge Nurse of your equipment and supply needs.
• Ensure that all personnel involved in providing care to the resident are aware of the resident's care plan and that nursing personnel refer to the resident's care plan prior to administering daily care to the resident
• Report suspected or known incidence of fraud relative to false billings, cost reports, kickbacks, etc.
• Treat all residents fairly, and with kindness, dignity, and respect.
• Assist in recording all incidents/accidents. File in accordance with established policies and procedures.
• Agree not to disclose resident's protected health information and promptly report suspected or known violations of such disclosure to the Administrator.
• Other duties as assigned by the supervisor/DON/Administrator. Supervisory Requirements This position has no supervisor responsibilities

Qualification

Education and/or Experience

Must possess, as a minimum, a high school diploma or GED.

Must have exceptional communication and customer service skills.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations.

Ability to write reports, business correspondence, and procedure manuals.

Ability to effectively present information and respond to questions from managers and employees.

Mathematical Skills

Ability to apply concepts such as fractions, percentages, ratios and proportions to practical situations.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.

Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Certificates, Licenses, Registrations

To perform this job successfully, a basic knowledge of medical terminology and nursing practices is helpful

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The employee must occasionally lift and/or move up to 25 pounds. Prolonged use of a desk top or laptop computer. While performing the duties of this job, the employee is regularly required to sit, stand; walk and talk, read or hear. Frequent use of all office related equipment to include; copier/scanner/fax, telephone, and calculator. May be necessary to assist in the evacuation of residents during emergency situations. Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually low to moderate.

We are an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status, or any other legally protected status.