UNIT SECRETARY at Westchester Medical Center – Poughkeepsie, New York

Job Summary

The Unit Secretary assists the professional nursing staff by performing specific tasks contributing to the care of the patient and the functional operation of the unit. These clerical and receptionist functions are performed under the direction and supervision of the Nurse Manager, Charge Nurse, and/or registered nurse.

Responsibilities

Receptionist Function

• Receives and delivers messages in an accurate, courteous and timely manner.
• Coordinates activities on the unit including but not limited to: Directing transportation: Scheduling patient procedures and treatments.
• Answers phones quickly with professional phone etiquette. Able to assist callers by providing information requested.
• Notifies IS/Maintenance departments for necessary repairs, and informs Business Coordinator in a timely manner.

Clerical Function

• Transcribes physician orders from physician order sheet to treatment records and/or care maps and enters in computer system as needed.
• Transcribes orders accurately, using the correct form and proper medical terminology.
• Enters orders in Invasion correctly, forwards to appropriate department and transcribes on the care map and/or treatment record.
• Enters patient factors in Invision, labels chart correctly, and transcribes on the caremap and/or treatment record.
• Physician consults; enters in Invision, and notifies physician’s office/service.
• Reports new medical orders to nurse in a timely manner.
• Obtains previous medical charts from Health Information Management department.
• Enters charges into Invision system for completed patient procedures.
• Faxes the Discharge information and Medication records to the Primary Physician and/or Home Care as applicable.
• Documents all patient information on the caremaps and carries over onto extended caremaps. Retrieve information from Nursing Admission Assessment, ER documentation.
• Gathers information for Nursing QI projects. Provides support re: data gathering reporting.
• Anticipates the needs of the Physicians and nursing staff. Consistently is aware of and provides assistance as needed.
• Serves as a resource for colleagues and new employees. Assists in orientation of new personnel. Consistently and proactively provides guidance to other staff members.

Maintains the Medical Record.

• Reviews charts daily for adequate sheeting and replaces/adds required forms as needed.
• Reviews charts daily for omitted Physician’s signatures and progress notes.
• Duplicates and/or faxes records as necessary.
• Assures completeness of medical record on all patients having invasive procedures. Initiates Pre–Op Checklist by reviewing the chart for copies of the required diagnostic work-up.
• Inputs patient discharges into Invision system.
• Processes patient charts after discharge making sure all papers are stamped with the patient addressograph and all forms have been collected and filed correctly (i.e. graphic sheet, I&O sheet, caremap). Wipes down chart after discharge.
• Reviews chart on return from a procedure and/or transfers to insure all forms are stamped with addressograph. Notifies Nurse Manager when departments are non-compliant.

Assures adequate level of supplies in the Department.

• Maintains adequate supply of admission charts.
• Keeps file system supplied and in order. Assesses supply of forms and med room supplies on unit and orders as needed.

Performs other related duties as assigned.

Qualifications/Requirements

EXPERIENCE

• A minimum of one to two years of experience in an office setting with a working knowledge of medical terminology preferred.
• Demonstrates proficiency in Key boarding and other computer skills required to enter orders/charges.

EDUCATION

High School Diploma or equivalent.