Primary Function

Responsible for viewing and processing physician orders in the electronic medical record, transcribing physician orders when needed especially during downtime procedures, maintaining bed management records, accessing lab results on the computer, performing receptionist and clerical duties, and coordinating non-nursing services within the unit.

Responsibilities

Initiate, assemble and maintain accurate, functional medical records for all patients in the assigned unit. Accurately view and process any physician orders in the electronic medical record. Accurately transcribe written physician orders when needed especially during downtime procedures and complete all necessary forms, requisitions and communications necessary to implement orders and record clinical data, as appropriate. Follows through to obtain missing information.

Maintain a proper inventory supply of paper forms needed in order to provide continuous service, minimizing downtime and maintain a safe, clean and functional working environment in the nursing station and nursing area. Responsible for updates to all unit forms as well as managing their storage.

Courteously, greet and assist visitors, screen telephone calls, and answer call buttons through nurse’s station intercom or in person in the patient’s room as applicable and direct to appropriate caregiver. Process mail and other correspondence. Make phone calls to relay patient information and schedule appointments as directed. Answer inquiries on procedures and policies relating to departmental functions.

Prepare medical record upon discharge of patient.

Copy medical records and obtain necessary discs for patient transfers/discharges to other facilities.

Accurately maintain patient census management manually, as well as electronically.

Assist with accessing or retrieving reports as requested.

File documents following standard procedures; maintain medical records in a neat and orderly manner.

Attend daily Interdisciplinary Discharge Rounds and keep the log of potential discharges for that day or the next day.

Obtain the Advanced Directive List and Discharge Flag Report from the unit’s printer for shift-to-shift safety huddles daily.

Obtain the overdue lab specimen report from the unit’s printer for distribution to the unit’s RN and C N A staff daily.

Hourly floating as necessary to fill in for open unit secretary areas throughout the inpatient units.

Print lab slips as necessary especially during downtime procedures.

Order; keep track; and file equipment (Wound VACs; specialty beds/mattresses) paperwork as applicable.

Orient new staff members into the role of unit secretary to all the job responsibilities as indicated throughout the job description.

Communicate pertinent patient care information and general information to the appropriate nursing staff.

Performs all other related duties as assigned.

Job Qualifications and Requirements

High School diploma and a minimum of one year job-related experience or equivalent are required. Basic computer skills and medical terminology are also required.

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.