Nursing Unit Clerk Responsibilities

Nursing Unit Clerk Responsibilities

• Know the identity of those having access to patient charts
• Print and correctly identify patient forms
• File reports and results, correctly dividing charts if necessary
• Put away charts when not in use
• Thin charts when they become too full
• Review charts frequently for orders and assist doctors in locating charts
• The Consent to Health Care form must be signed by the patient, allowing the physician to perform surgery.

Chart Information

• The Kardex is a quick reference tool for each patient in the nursing unit.
• Unit clerks are permitted to complete information on the Consent Form
• Emergency Department Assessment forms are completed by the nurse, documenting clinical observations for the patient.
• The Pre-Operative Checklist ensures that pre-operative tests and procedures are completed before surgery.
• Braden Risk Assessment, Diabetes Record, Consultation Request, Anticoagulant Record, and MRSA and MDRO Screening may be found in a patient's chart.

Important Forms and Records

• Diabetes Record: Used to record insulin amounts and blood results
• Ambulance Crew Report: Completed by paramedics for ambulance patients
• Kardex: Holds patient information such as activity orders, medical history, diagnostic tests, diet, physicians, allergies, nursing care plans, and tests
• Emergency patient charts may include: ER/Ambulatory Care Clinical forms, Ambulance crew reports, Nurse's notes, Intake/Output Records, Triage forms, and Nurse to Nurse reports
• Pre-op checklist, Pt. Questionaire, Anaesthetic Record, Peri-Operative Nursing Record, OR surgical count sheet and Post-Anaesthetic Care for surgical patients.
• Patient Questionnaire: Used by anaesthetists and nurses to gather current information on the patient's medical history for treatment.
• Vital Signs Record: Used to graph patient temperature, pulse, respiration, and blood pressure
• Signature Record: For accurate documentation of staff members' signatures for charting.

Patient Chart Management

• The purpose of the patient chart is to maintain a record of patient information, doctor's orders, and nursing needs
• When a chart becomes full, MARs, Vital sign records, flow sheets, and Nurses' Notes may need to be taken out
• Six types of surgical forms might be added to a patient's chart if they are having surgery: pre-op checklist, Patient Questionnaire, Anaesthetic Record, Peri-operative nursing record, OR surgical count sheet, and Post-anesthetic Care
• Unit clerks must forward transferred patients' reports to the new units and send discharge reports to Health Records
• A patient who has been in a hospital for six months is to have a MRSA & MDRO screening form.

Medical Imaging Reports

• Seven types of medical imaging reports are filed in a patient's chart: X-rays, CT Scan, Ultrasound, Nuclear Medicine, MRI, Interventional Radiology, and Fluoroscopy
• Braden scale: Used to assess patient skin condition to prevent pressure sores
• Anaesthetic Record records observations and medicines given to a patient during surgery
• Ambulatory Daycare/General Day Care: Treatment area for patients who require medical but not overnight care
• Outpatient: Patient receiving care in a healthcare facility but not staying overnight

Nursing Units and Patient Status

• Twelve regular hospital nursing units are mentioned: Cardiovascular, Gynaecology Surgical, Medical, Neurology, Oncology, Paediatrics, Obstetrics, Orthopaedics, Psychiatry, Rehabilitation, Surgical, and Urology
• An inpatient is a patient admitted to a healthcare facility for overnight care and treatment.

Abbreviations

• Full terms for various abbreviations are provided (PRN, ATD, RLQ, etc.)