Unit Secretary

Unit Secretary Job Summary

Unit Secretary prepares and compiles records in the nursing unit.

• Records information in the clinical record as outlined by center standards.

• Copies information, such as resident’s temperature, pulse rate, and blood pressure, from nurses’ records onto resident’s medical records.

• Records diet instructions.

• Keep a file of medical records on residents in the unit.

• Prepares notice of resident’s discharge to inform the business office.

• Requisition supplies designated by nursing staff.

• Answer telephone and relay messages to residents and nursing staff.

• Direct all visitors to residents’ rooms.

• Checks resident m, , and/or resident pictures and obtains replacements as necessary.

• Prepares name tags for doors and places them on the door upon admission and as needed

• This clinical records at least monthly.

• Audits new admission charts using the Quality Improvement audit tools.

• Faxes orders to physicians, as requested.

• Assembles and maintains complete admission and discharge/transfer packets for assigned units.

• Schedules transportation to physician appointments or other appointments, as required. Arrange escort, as needed.

• Ensure lab printer and fax are set up correctly and ready for operation.

• Tracks H&P due, Informs supervisor of annual H&Ps due.

• Performs any various work assignments as may be required.

• Know and respect residents’ rights.

• Informs and supports residents in exercising their rights.

• Ensure protected health information is kept confidential.

• Reports complaints made by residents to the supervisor.

• Reports all allegations of resident abuse, neglect, and/or misappropriation of resident property.

• Follows established safety policies and procedures.

• Observes safety needs of residents as indicated in care plan; participates in restraint reduction program.

• Wears and/or uses safety equipment and supplies when indicated and adequately trained to use.

• Demonstrates job-specific knowledge of fire and disaster preparedness during drills or actual situations.

• Attends and participates in scheduled in-service training, educational classes, and meetings to maintain current certification as mandated by regulatory agencies and company policies.

• Participates in the QAA process.

• High School graduate or equivalent. Must have legible penmanship, knowledge of medical symbols, abbreviations, and terminology.