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CNA/Medical Clerk - Inpatient
Job Code:2021-04-020
Department:Inpatient
FT/PT Status:Regular Full Time
Salary Minimum12.22
Salary Midpoint14.36
  
Position Closes:
Open Until Filled 

Job Responsibilities & Qualifications:

Primary Function

The float medical clerk works under the direction and supervision of a Registered Nurse. Under supervision the incumbent is responsible for a variety of nursing assistant and clerical duties established by the Nurse Manager. The float nursing assistant/medical clerk provides nursing assistant and clerical support between the Inpatient, Outpatient, and Emergency Departments. Primary support is given to the Inpatient Department and coverage is for weekend and evening support. The incumbent will also function as the float clerk to provide clerical support during periods of absence of the Outpatient and Emergency Room Departmental clerks and may be subjected to on-call and callback.

 

Job Description

  • Takes and records vital signs and reports deviations to the registered nurse.
  • Assists patients with daily living activities, i.e., bathing, oral hygiene, changing bed linen, feeding, etc.
  • Collects specimens (urine, stool, throat cultures, and sputum)
  • Completes finger stick glucose monitoring.
  • Dresses wounds and applies soaks
  • Assists primary care providers with diagnostic test, examining patients, etc.
  • Monitors intake and output, including monitoring IVs.
  • Performs vision acuity (Snelling)

Inpatient Department

  • Receptionist duties include answering telephone and directing calls to the appropriate individual and/or answers routine questions concerning the inpatient unit.
  • Initiates the admission process by assembling the admission chart and preparing the chart for patient admission to the inpatient unit.
  • Completes the admission process by transcribing physician orders to the appropriate record, including transcription of medications to the Kardex; requisitioning laboratory, radiology, or other tests; contacting ancillary medical services as ordered to schedule appointments or arrange patient consultation; and arranges meals from dietary.
  • Completes discharge process by assuring primary care provider’s documentation is complete. Initiates final disposition of chart from Inpatient to Medical Records Department. Schedules follow-up appointments; arranges laboratory, radiology, or other tests, and assures discharged patient has transportation. Transfers patient chart to pharmacy to finalize discharge medications.
  • On a daily basis, transfers primary care provider’s orders to the appropriate record; maintains dietary changes, arranges laboratory, radiology, or other tests, and assures discharged patient has transportation. Transfers patient chart to pharmacy to finalize discharge medications.
  • On a daily basis, transfers primary care provider’s orders to the appropriate record, maintains dietary changes, arranges laboratory, radiology, or other tests, contact ancillary medical services as ordered to schedule appointments or arrange patient consultation.
  • Documents vital signs and other measurement data to the appropriate record. Maintains inpatient census information.
  • Generates and files patient health summary on admission, maintains inpatient records such as filing laboratory and radiology reports; assures appropriate forms and number of forms, etc.

Outpatient and Emergency Room Department

  • Answers unit telephone, supplies routine information receives and relays messages to outpatient and/or ER staff. Receives patients and registers patients into the outpatient and/or ER log. Maintains all patient data in ER log.
  • Arranges for patient transfers and assembles all documents required for transfers. Prepares monthly reports as designated by the Outpatient and/or ER Nurse Supervisor.
  • Retrieves patient’s charts from Medical Records, requisitions laboratory or radiology studies, through a computerized system, ordered by physicians, obtain results and routes and files results appropriately.
  • Records telephone messages pertaining to such things as detailed laboratory results, refers all urgent communication to the professional staff for immediate action. Initiates calls as requested by staff.
  • Arranges and schedules clinical appointments through computerized system, services and consultations for patients during routine clinic hours and initiates forms for authorization to perform special procedures. Requests transportation for patients from within or outside the immediate family.
  • Assists with the billing process by identifying third-party resources.
  • Prepares and maintains packet of forms used by the Outpatient and Emergency Room Departments.
  • Maintains clerical supplies by checking stock and requisitions replacements as appropriate. Orders unit supplies through requisitions from the Outpatient and ER staff.
  • Performs other related duties as assigned.
  • May be necessary to work when Administrative Leave is granted if patient care would be compromised.

 

 

 

Job Knowledge

  • Knowledge and skill to perform basic clinical nursing care to acutely ill patients and assist patients in their daily living activities.
  • Knowledge and skill to assist the primary care provider in treatment and examinations performed in the Outpatient, ER, or Inpatient setting.
  • A practical knowledge of performing prescribed treatment plans such as dressing changes or soaks.
  • Knowledge of proper handling and collection of specimens, performing vital signs, and recognizing abnormal values.
  • Basic knowledge of diseases and illnesses and the ability to recognize and report changes in the patient’s condition to the registered nurse.
  • A practical knowledge of the medical facility’s organization and services, the basic rules and regulations governing visitors and patient treatment, COBRA, and practical knowledge of standard procedures, medical records, and medical terminology.
  • Knowledge of typing and computer use since both are used in the performance of position duties. Familiarity with computerized based appointment scheduling, referral, and diagnostic scheduling packages.
  • Knowledge of Inpatient, Outpatient, and ER operating procedures such as the emergency communication systems, transfers, referrals, and treatments.
  • A good working knowledge of terms describing diseases, medical and surgical procedures, as well as standard abbreviations used by the medical staff.
  • A thorough knowledge of recording and referral procedures.
  • Knowledge of requisitioning supplies and maintaining clerical supply levels.
  • Knowledge of filing procedures and communication skills to relay medical information to members of the unit and other services of the hospital.
  • Applicant must have a valid North Carolina driver’s license.

 

Education/Experience

  • High School graduate or GED, successfully completed an accredited program in Nursing Assistant, and has been certified as a Nursing Assistant.
  • Preference given to applicants who have specialized training in clerical duties and CNA.
  • Six months experience in clerical duties, i.e. typing, computer use, and filing. Experience can be documented through education or work related experiences.
  • Proficiency rated at 6 weeks.

 

Contacts with Others

Personal contacts are with patients, families, and friends of patients, visitors to the hospital, physicians, nurses, and all hospital personnel. Contacts with patients are to provide nursing care. The clerk may assist the patient in obtaining hospital services available or assist in arranging transfers. There is also contact with other hospital departments regarding nursing services and treatment.

 

Confidential Data

The incumbent has access to highly confidential patient medical and personal information. The Privacy Act of 1974 mandates that the incumbent shall maintain complete confidentiality of all administrative, medical and personnel records and all other pertinent information that comes to the individual’s attention or knowledge. The Privacy Act carries both civil and criminal penalties for unlawful disclosure of records. Violation of such confidentiality shall be cause for adverse actions.

 

Responsibility for Accuracy

The incumbent is responsible for accuracy of work performed. The charge nurse, supervising registered nurse, or immediate supervisor reviews work for accuracy and determines steps to prevent errors from reoccurring. Patient care provided by the incumbent contributes to completion of the prescribed plan of care and disposition of the patient. Incumbent initiates and follows through on all clerical procedures during the patient care and treatment process. Completion of duties affects the attitude of patients and efficiency with which the hospital provides service and therefore could have a negative effect on patient outcomes.

 

Incumbent performs nursing and clerical procedures pertinent to Inpatient, Outpatient, and ER care and treatment. Uses judgment in determining priority of nursing care tasks based upon the diagnosis of the patient, their condition and special circumstances related to their needs. Assembles patient records according to prescribed format. Inserts forms in chart as necessary. Interviews patients to update insurance information. Initiates appropriate requisitions from hospital staff. Records appropriate data into departmental log.

 

Mental/Visual/Physical

Work in the various services within the nursing department requires considerable waling, standing, bending, pushing, and lifting in helping patients to and from beds, wheelchairs, and stretchers. These same activities are required in moving equipment and medical supplies. May occasionally move more than 15 pounds.

 

Resourcefulness and Initiative

Incumbent works under the administrative supervision of a Supervisory Clinical Nurse, GS-610-11, who administers control of the Inpatient Department’s functional duties. Receives technical directions from the Charge Nurse. Incumbent is responsible for initiating and following through on recurring clerical assignments. Work is primarily reviewed in terms of overall quality and efficiency of service provided to patients and staff.

 

Guidelines consist of nursing and medical procedures, inpatient, outpatient, and emergency room manuals, Privacy Act guidelines, hospital policies and procedures. The incumbent uses judgment in locating and selecting the most appropriate guidelines, references and procedures for application and in making minor deviations to adapt the guidelines to specific cases. Unusual developments are referred to the supervisor.

 

Environment

Must be flexible in working hours. Work is performed in the hospital setting, which is responsible for treating patients with a wide variety of medical problems. Incumbent is frequently exposed to communicable diseases. Incumbent is required to comply with Employee Health Program guidelines including current immunization status of identified communicable diseases and safety precautions are sometimes necessary, such as use of personal protective equipment as required by hospital policy.

 

Customer Service

Consistently demonstrates superior customer service skills to all patients/customers by displaying Spotlight on Success I CARE behaviors and skills. Ensure excellent customer service is provided to all patients/customers by seeking out opportunities to be of service.