Essential Responsibilities:

• After physician completes charts, check and prioritize in order to obtain STAT and discharge orders.
• Transcribes all orders to the HER and other appropriate documents.
• Notifies the appropriate department(s) of STAT orders.
• Initiates, assembles, and maintains charts for all patients; makes up new charts as needed.
• Charts routine items such as vital signs, weights, diet, I/O etc.
• Checks charts and maintains proper forms.
• Advises Charge Nurse or Director of Nursing of incomplete documentation.
• Notifies office of admissions in a timely manner.
• Pulls pharmacy and medication nurse copies of physician’s orders and handles them appropriately.
• Transcribes physician’s orders as necessary to implement orders.
• Orders supplies through Central Supply.
• Makes copies of necessary documentation when a patient is being transferred to another medical facility with the supervisor’s/Registered Nurse’s direction.
• Informs the nursing supervisor or Registered Nurse on completion of x-ray and lab procedures and acquires patient’s meal if required.
• Reminds nursing personnel of specimens that are to be collected.
• Notifies housekeeping of room numbers after dismissal.
• Gives exchange report to other unit clerks and health care personnel providing accurate and complete information on patient(s) at the change of shift.

OTHER SIGNIFICANT REQUIREMENTS:

• Maintains confidentiality while working with confidential matters daily.
• Provides service direct to patients while maintaining a positive patient relations
• Follows aseptic procedures and procedures for using precautions when involved in direct patient contact or handling potentially infectious materials.
• Follows safety guidelines and policies for the Hospital District.

Experience

• 1 year(s): clerical and medical terminology experience preferred

Education

• High School or better

Licenses & Certifications

• (CPR) Cardiopulm Resus

Skills

• Organizational Skills
• Medical Terminology
• Communication Skills
• Bilingual

Behaviors

• Team Player: Works well as a member of a group
• Dedicated: Devoted to a task or purpose with loyalty or integrity
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization