Employment Type:

Full time

Shift:

12 Hour Day Shift

Description:

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Medical Record Maintenance
• Assembles and maintains patient charts in the prescribed order per chart order throughout the hospital stay. Reviews chart for:
- Correct order
- Correct chart
- Forms with all PLUE labels
- Forms from Formsfast
• Files labs and reports in the correct patient record.
• Initiates universal forms during computer down times.
• Prepares Foley Forms as required.
• ""Thins"" patient records per Medical Record Standards.
• Prints appropriate forms from FormsFast such as consult sheets and pre-op checklists.
• Checks for progress notes, prints, and adds to patient chart as necessary.
• Obtains and stores ""past"" medical records per Medical Record Standard.
• Reviews physicians orders on an ongoing basis and documents laboratory and cardiology orders on clipboard (as necessary).
• Verifies name of primary care physician and patient’s home phone number with the patient, and corrects on face sheet as necessary. Initials face sheet once information is verified or corrected.
• Verifies that observation status patient records are housed in the appropriate observation chart.
• Generates Meditech reports as directed by Patient Care Manager.
• Monitors for consult orders, contacts consultants, and documents notification of consult.
• Copies restraint sheets daily and submit to Patient Care Manager.
• Enters written orders into the electronic medical record as necessary, and documents date, time and signature on order sheet.
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Comments:
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Unit Hospitality/Service Excellence Ambassador
• Greets and directs patients, visitors and hospital personnel.
• Participates in unit-specific efforts to improve patient, colleague, and physician satisfaction survey scores.
• Answers phone, directs callers appropriately or takes message.
• Participates in Service Excellence Committee meetings as requested.
• Assists with the admission process as designated by the Patient Care Manager, including inspecting patient’s room prior to arrival to ensure that it is ready for patient.
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Comments:
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Materials and Supplies
• Receives orders verbally or in writing for supplies necessary for unit operations.
• Submits orders through system(s) as required.
• Ensures that an adequate supply of materials and supplies as assigned are readily available for unit use.
• Receives supply or material order and distribute or store as required.
• Retrieves medical record information from the pneumatic tube system.
• Participates in stocking and maintenance of PPE in isolation stations.
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Comments:
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Clinical Functions
• Participates in patient rounding as directed.
• Answers call bells in person.
• Assists patients in completing dietary selections.
• Distributes ice and water to patients as directed.
• Performs 1:1 patient observation as assigned/needed within a specific area of care provision.

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Comments:
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Communication
• Receives requests from patients, colleagues, physicians, families, etc. and responds appropriately. (Contact nursing staff; seek assistance from other colleagues, utilizing Charge Nurse, Clinical Care Supervisor, or Patient Care Manager as appropriate).
• Pages and/or locates physicians and other personnel upon request.
• Notifies RN when patient is called for OR or test.
• Informs RN of ""stat"" orders immediately if/when notified by physician.
• Participates in the orientation of new colleagues as directed by the Patient Care Manager or Educator.
• Participates in the report and hand-off process with nursing staff obtaining periodic updates throughout the day.
• Checks fax machine for missed laboratory specimen reports and places them in designated log book.
• Receives and/or reviews all written, verbal and electronic communication posted, and responds appropriately, including following new procedures and protocols.
• Notifies appropriate physician or colleague of receipt of faxed communication. Manage and facilitates faxed information as needed.

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Comments:
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Patient Discharge Functions
• Works collaboratively with Clinical Care Supervisor to facilitate patient discharges as requested.
• Obtain patient signature on 2nd notice of ""Important Message From Medicare.""
• Ensures that Discharge Postcard is on the patient chart for the RN to complete at the time of discharge.
• Completes follow up phone calls for discharged patients and assists in the process of making post discharge appointments with appropriate physician offices.
• Faxes copy of discharge instruction to primary care physician office.
• Assists with arrangements for home care and equipment needed for h