Under supervision, this position provides clerical and unit support functions to hospital patient care units to promote an organized, efficient and smooth functioning unit. This position works closely with licensed and non-licensed hospital personnel and physician team members by coordinating information, preparing the Medical Record chart, maintaining census data, and transcribing physician orders into the appropriate in-house system application. This position is required to maintain current knowledge and competencies with all in-house nursing and clinical system applications. This position regularly provides unit secretary coverage for multiple nursing units. This position requires the successful completion of the Botsford Hospital Unit Secretary Training program and unit-based Unit Secretary Orientation program, inclusive of demonstrated competencies in the performance of all primary duties and responsibilities.
· Utilizing processes and procedures defined and prescribed by the Unit Secretary training program, accurately transcribe and processes physician's orders into the appropriate nursing or clinical system database, updates the Nursing Care Plan, maintains census records and notifies responsible nurse of new and/or changed orders and other deviations.
· Checks the unit printer a minimum of every four hours for paperwork, physician instructions, lab results, etc., and handles appropriately, ensuring all documents are labeled accurately with patient information.
· Orders and maintains patient supplies and equipment for the unit using the appropriate order entry system applications.
· Initiates, assembles and maintains the Medical Record chart for all patients upon admission to the unit, using the appropriate data sequence. Condenses or truncates the chart following defined guidelines as necessary to reduce file size.
· Disassembles patient's Medical Record after the patient is discharged from the floor, completes the appropriate checklist and then places the chart in the Medical Records bin.
· Maintains twenty-four hour unit census by recording all admissions, discharges and transfers in the appropriate applications and communicates changes in patient status with Bed Management/Admitting, in a timely manner.
· Maintains patient facilitator and staffing deviation sheets. Communicates changes to unit management in a timely manner.
· Performs reception duties including: receiving, directing and assisting visitors, answers telephones in a timely and professional manner, taking and relaying messages as needed.
· Prepares and maintains a variety of files, records and schedules as they pertain to the operation of the unit. Distributes mail within the unit. Maintains a general orderliness of the unit desk area, including storing of supplies and equipment.
· Coordinates work tasks with other personnel within the unit as well as within other units and departments in order to ensure the smooth and efficient flow of information. Regularly provides unit secretary coverage for multiple units, as required.
· Supports, cooperates with and follows hospital and unit-specific procedures and programs for quality assurance, safety, including universal precautions and safe work practices, established fire/safety/disaster plans, risk management, and security. Reports unsafe working conditions, equipment repair and maintenance needs.
· Responds promptly to call lights using the intercom and informs appropriate nursing personnel of patient needs.
· Provides an orientation of the unit secretary function for licensed and non-licensed nursing staff on the unit and participates in the orientation of new unit secretarial staff to the unit, as needed.
· Participates in nursing and clinical computer system updates and in-services. Maintains and demonstrates current knowledge and competencies navigating and using in-house system applications to include but not limited to: Amigo Order Entry and patient maintenance, Nursing Care Plan application, SoftLab Order Entry, SoftLab Query, Bed Ready system, HBOC and CDR-WEBB.
· Runs "stat" and regular errands, as directed.
· Escort patients upon admission, transfer or discharge as needed.
· Performs 1:1 patient supervision as directed.
· To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.
· Minimum Education: Requires a level of knowledge normally acquired through completion of a high school diploma or GED program. Requires the successful completion of the Unit Secretary Training program and Unit-Specific Unit Secretary Orientation within the probationary period.
· Minimum Work Experience: Requires pc literacy, keyboard proficiency and general knowledge and experience with clerical functions and data entry processes. Experience in a health care or hospital environment is a plus. Familiarity with medical terminology is preferred. Experience with Amigo, Soft Lab and HBOC database software is highly desirable.
· One year hospital unit secretary experience required