JOB DESCRIPTION

• Prepares and maintains a confidential, accurate, organized, and updated electronic health record for each assigned client. Maintains the timeliness of documentation as outlined in facility protocols, under appropriate supervision.
• Inventories clients’ property in an accurate manner. Stores property and ensures its security. Releases property in an accurate manner to clients who leave the unit.
• Collects urine specimens in accordance with Agency policy and procedures.
• Effectively orients clients to program and facility by explaining issues including, but not limited to: rule infractions that may result in termination, the hours of service availability, clients’ rights and the grievance procedure and costs for which they may be responsible.
• Prepares beds and assists with general cleaning while adhering to Agency and program safety policies and procedures as well as required OSHA standards.
• Accurately accounts for the whereabouts of each client by conducting and documenting facility whereabouts every thirty (30) minutes in accordance with Agency policy and procedures.
• Accurately administers an alco-sensor on all clients at time of admission and discharge and documents in the client’s electronic health record in an accurate and timely manner.
• Assists with intake documentation as necessary (e.g., consent for treatment, consents to release information, face sheet, etc.) and maintains this information in the electronic health record.
• Provides clients education through lectures, the use of audio and visual equipment, and reading materials. Informs clients about self-help groups and other community resources.
• Complies with all Agency security standards, including procedures and electronic equipment/devices.

This job description in no way states or implies that these are the only duties to be performed by this employee.