Unit Secretary – Lord Chamberlain Nursing & Rehabilitation Center – Stratford, CT

Purpose of Your Job Position

The primary purpose of your job position is to assist the Nurse Supervisor/Head 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.

Delegation of Authority

As Unit Secretary you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

¨ Record medical and administrative information in accordance with our established charting and documentation policies and procedures.

¨ Prepare and process inter departmental forms.

¨ Coordinate the scheduling of multiple tests, appointments and consults (i.e. outpatient doctor visits, hospital visits, etc.) to expedite patient care.

¨ Prepare and maintain patients’ medical records and record information on the graphic sheets, (I&O TPR’s, weights, etc).

¨ Initiate weekly & daily cna assignment sheet and the daily sign-in sheet.

¨ Prepare X-Ray, laboratory and other requisitions. File all reports in the medical record.

¨ Track and schedule annual blood-work and H&P tests according to state code.

¨ Monitor Physician Visit List and phone physicians to visit residents every 30 or 60 days.

¨ Prepare data/information for Medical Director’s rounds.

¨ Thin active charts monthly and keep them accessible.

¨ Maintain 2 copies of the DNR status sheet at all times.

¨ Pull doctor orders bi-monthly for pharmacy pick- up.

¨ Keep Head Nurse apprised of unit activities and pertinent information when unit manager is off the unit.

¨ Maintain an up-to-date roster of residents for your assigned unit.

¨ Obtain reports from the unit mailboxes in the DNS & Business Offices.

¨ Communicate observation of patients’ activities to the nurse.

¨ Utilize copy machine, fax and other equipment upon request.

¨ Fill out resident charge slips and submit to the Business Office.

¨ Answer telephone, page calls and deliver messages to residents, staff, etc., as necessary.

¨ Maintain a current listing of physician phone & fax numbers for your assigned unit.

¨ Record appropriate resident identification data on designated medical records, wristbands, ID cards, photo, etc., as required.

¨ Record vital signs as directed.

¨ Forward new diet orders and/or diet changes of the Director of Food Services.

¨ Keep nursing service personnel informed of resident’s appointments.

¨ Admit, transfer, and discharge residents. Assist in arranging for transportation, escorting them to discharge/transfer area, etc., as necessary.

¨ Coordinate necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.

¨ Forward completed charts of discharged residents to the Medical Records Department.

¨ Deliver mail, flowers, etc., to residents as necessary.

¨ Direct visitors to resident rooms, office areas, etc., as necessary.

Committee Functions

¨ Attend various committee meetings of the facility (i.e., Infection Control, Safety Committee, CQI, etc.) as required.

¨ Provide data to the CQI Committee as requested.

¨ Implement recommendations from established committees as instructed.

Personnel Functions

¨ Assist in the orientation of newly assigned personnel as directed.

¨ Interpret department policies and procedures to personnel, residents, visitors, etc., as directed.

¨ Assist the Nurse Supervisor/Head 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.

¨ Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift.

Nursing Care Functions

¨ 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.

¨ Assist in escorting resident’s to/from activity and social functions.

¨ Encourage attending physicians to record and sign progress notes, physicians’ orders, etc., on a timely basis and in accordance with current regulations.

¨ Report administrative problem areas to the Director. Assist in developing and implementing corrective action.

¨ Call funeral homes when requested by the Head Nurse.

Staff Development

¨ Assist as necessary in the orientation of newly assigned personnel to your unit.

¨ Attend in-service training programs as scheduled.

¨ Attend and participate in annual OSHA and CDC in-service training programs for hazard communication, TB management, and bloodborne pathogen standards.

¨ Attend and participate in advance directive in-service training programs for the staff and community.

¨ Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession.

Safety and Sanitation

¨ Follow established safety regulations in the use of equipment and supplies.

¨ Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.

¨ Assist in maintaining nursing service work areas (i.e., nurses’ stations, medicine preparation rooms, etc.) in a clean and sanitary manner.

¨ Participate in all fire safety and disaster preparedness drills in a safe and professional manner.

¨ 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.

¨ Follow established infection control procedures when isolation precautions become necessary.

¨ Follow established procedures in the use and disposal of personal protective equipment.

¨ Report hazardous conditions or equipment to the Nurse Supervisor/Head Nurse.

¨ Follow established hand-washing techniques.

Equipment and Supply Functions

¨ Inform the Nurse Supervisor/Head Nurse of your equipment and supply needs.

¨ Follow established preventive maintenance procedures for maintaining your equipment and supplies in a safe and operable manner.

Resident Rights

¨ Maintain the confidentiality of all resident care information.

¨ Treat all residents fairly, and with kindness, dignity, and respect.

¨ Knock before entering the resident’s room.

¨ Report all allegations of resident abuse and/or misappropriation of resident property.

¨ Report complaints and grievances made by the resident to the Nurse Supervisor/Head Nurse. Follow facility’s established procedures.

Working Conditions

¨ Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ stations, resident rooms, etc.).

¨ Moves intermittently during working hours.

¨ Is subject to frequent interruptions.

¨ Is involved with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

¨ Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

¨ Communicates with the medical staff, nursing personnel, and other department supervisors.

¨ Works beyond normal working hours and on weekends and holidays when necessary.

¨ Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

¨ Attends and participates in continuing educational programs.

¨ Is subject to injury from falls, burns from equipment, odors, etc., throughout the workday, as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

¨ Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

¨ May be subject to the handling of and exposure to hazardous chemicals.

Education

Must possess, as a minimum, a high school diploma or its equivalent.

Experience

None required. On-the-job training provided. However, a basic knowledge of medical terminology and nursing practices is helpful.

Specific Requirements

¨ Must be able to read, write, speak, and understand the English language.

¨ Must possess the ability to make independent decisions when circumstances warrant such action.

¨ Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

¨ Must possess the ability and willingness to work harmoniously with other personnel.

¨ Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

¨ Must be willing to seek out new methods and principles and be willing to incorporate them into existing nursing practices.

¨ Must be able to relate information concerning a resident’s condition.

¨ Must not pose a direct threat to the health or safety of other individuals in the workplace.

Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

¨ Must be able to move intermittently throughout the workday.

¨ Must be able to speak and write the English language in an understandable manner.

¨ Must be able to cope with the mental and emotional stress of the position.

¨ Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.

¨ Must function independently and have flexibility, personal integrity, and the ability to work effectively with residents, personnel, and support agencies.

¨ Must meet the general health requirements set forth by the policies of this facility, which include a medical and physical examination.

¨ Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.

¨ Must be able to push, pull, move, and/or lift a minimum of 40 pounds to a minimum height of 3 feet and be able to push, pull, move, and/or carry such weight a minimum distance of 4 feet.

¨ May be necessary to assist in the evacuation of residents during emergency situations.

Job Type: Full-time

Pay: $16.00 – $17.00 per hour

Benefits: