Ward Clerk Full-Time

Job Title: Ward Clerk

Status: Full-Time
Location: Orchard Post Acute
Salary Range: $17.48 – $18.00 per hour (DOE)
Reports To: Nurse Supervisor / Charge Nurse

General Purpose

The primary purpose of this position is to assist the Nurse Supervisor/Charge Nurse in the day-to-day recording and charting of medical and administrative information in accordance with current federal, state, and local standards, guidelines, and regulations governing medical records. This role ensures that medical records are maintained in an accurate, informative, and timely manner.

Essential Functions Disclaimer

Every effort has been made to identify the essential functions of this position. However, this does not imply that these are the only duties required. The omission of specific duties does not exclude work that is similar, related, or an essential function of the position.

Essential Duties and Responsibilities

• Record medical and administrative information in accordance with established policies and procedures

• Maintain Daily Census Reports and submit to Nurse Supervisor/Charge Nurse

• Maintain an up-to-date resident roster for the assigned unit

• Complete resident charge slips and submit to the Business Office

• Answer telephones, page calls, and deliver messages as needed

• Maintain current emergency contact lists for the unit

• Track and forward tardy and absentee reports to the Business Office

• Record resident identification data on medical records, wristbands, and ID cards

• Accurately transcribe physicians’ orders to care plans, medication records, and treatment plans

• Report discrepancies in orders, charting, or documentation to the Nurse Supervisor/Charge Nurse

• Review medication cards for accuracy, completeness, and legibility

• Document nurses’ notes in an informative and descriptive manner

• Forward diet orders and changes to the Dietary Department

• Notify family members of changes in resident condition as directed

• Assist with resident admissions, transfers, and discharges, including documentation and coordination

• Prepare and forward discharged resident charts to Medical Records

• Participate in facility committees and meetings as required

• Assist with staffing schedules and assignments as directed

• Maintain positive working relationships with all departments

• Communicate new admissions and updates to nursing staff

• Greet and assist new residents upon admission

• Encourage timely physician documentation in accordance with regulations

• Notify families and coordinate services (e.g., funeral homes) as directed

• Participate in required in-service training programs (OSHA, HIPAA, Infection Control, etc.)

• Support infection control practices and reporting

• Ensure care plan awareness among staff and support compliance

• Report suspected fraud, compliance concerns, or irregularities

• Treat all residents with dignity, respect, and compassion

• Assist with incident/accident reporting per policy

• Maintain strict confidentiality of resident information (HIPAA compliance)

• Perform other duties as assigned by Supervisor, DON, or Administrator

Supervisory Requirements

This position does not have supervisory responsibilities.

Qualifications

Education and/or Experience

• High school diploma or GED required

• Prior healthcare or skilled nursing experience preferred

• Basic knowledge of medical terminology preferred

• Strong communication and customer service skills required

Skills and Abilities

Language Skills

• Ability to read, analyze, and interpret documents such as policies, procedures, and regulations

• Ability to write reports and correspondence

• Ability to effectively communicate with staff, residents, and families

Mathematical Skills

• Ability to apply basic mathematical concepts such as fractions, percentages, and ratios

Reasoning Ability

• Ability to solve practical problems and interpret a variety of instructions

Certificates, Licenses, Registrations

• Basic knowledge of medical terminology and nursing practices preferred

Physical Demands

• Ability to sit, stand, and walk throughout the workday

• Frequent use of computers, phones, and office equipment

• Ability to lift and/or move up to 25 pounds occasionally

• May be required to assist during emergency situations

Work Environment

• Skilled nursing facility environment

• Low to moderate noise levels

• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions

Additional Information

Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities at any time. This description outlines the general nature and level of work and is not intended to be a complete list of all duties, responsibilities, or skills required.

Equal Employment Opportunity (EEO) Statement

Orchard Post Acute is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other protected status in accordance with applicable law.