Medical Records Nurse

3 weeks ago

Newark NJ, United States Sinai Post Acute Nursing & Rehab Full time

POSITION SUMMARY:All Shifts Available
POSITION SUMMARY:
Under the supervision of the Director of Nursing, the incumbent utilizes a general understanding of the principles of nursing and basic physical assessment skills in the development of and implementation of individualized nursing care plans to ensure that the needs of the residents are met. He/she assists in the orientation of and supervision of nursing personnel, attends to the daily operations of the unit per shift, unit level, and assumes responsibilities of a leadership role as needed.
RESPONSIBILITIES/ACCOUNTABILITIES:
1 Takes an active role in direct resident assessment and care;
2 Supervises and coordinates nursing personnel in providing direct resident care in adherence to State and Federal regulations;
3 Formulates individualized nursing care plans utilizing the nursing process;
4 Assesses each resident daily and implements a change in the course of action as needed;
5 Assists the physician on rounds and ensures that pertinent information is communicated to and from him/her and orders are taken correctly;
6 Participates in the training and supervision of nursing personnel;
7 Utilizes effectively the general principles of leadership and supervision;
8 Manages conflict through effective problem-solving and communication skills;
9 Acts calmly and efficiently in handling emergency situations;
10 Prepares daily assignment of duties, treatments, and miscellaneous tasks;
11 Assists with implementation of facility’s Quality Improvement Program;
12 Assumes responsibility for the identification of potential safety hazards and for the identification of noncompliance with facility guidelines as set forth in the Policy and Procedure Manuals;
13 Maintains accurate resident care records and documents pertinent data reflecting the use of the nursing process;
14 Attends and participates productively in the resident care meetings, staff meetings and in-services;
15 Maintains active licensure;
16 Attends all mandated in-services;
17 Takes an active role in teaching (formal or informal presentation) with residents, families and staff;
18 Dispenses medication and performs treatments, as requested, and in accordance with Windsor Gardens Care Center policies and procedures;
19 Assures that each resident’s attending physician and family or responsible party are promptly notified of any significant change in the resident’s health condition;
20 Ensures that residents and families receive the highest quality of service in a caring and compassionate atmosphere which recognizes the individuals’ needs and rights;
21 Performs additional duties as requested.
SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS:
1 This position requires a current Registered Nurse License graduate of an approved New Jersey School of Nursing.
2 Up-to-date physical assessment skills and comprehensive knowledge of state nursing principles are also required.
3 Recent experience in geriatric or rehabilitative nursing and experience in supervisory capacity are preferred.
JOB SKILLS:
1 Must be in good physical and mental health.
2 Must have knowledge of procedures and techniques involved in administering simple treatments and providing related bedside resident care services.
3 Must pay attention to safety hazards to residents and self.
4 Must be familiar with location of various departments and regulations of the facility.
5 Must understand standard techniques used in providing personal services for residents and in caring for equipment and supplies.
6 Must have a good understanding of basic medical asepsis, sterile techniques and universal precautions to avoid infection of residents and self-contamination of equipment and supplies.
7 May be required to work rotating shifts and to work in different units as residents needs require; specific scheduling will be under the direction of the nursing supervisor.
8 Must possess the ability to positively interact with personnel, residents, family members, visitors, government agencies/personnel and the general public.
9 Must provide annual verification of a negative TB skin test.
PERFORMS RELATED DUTIES:
1 Interacts with residents, families, visitors and employees.
2 He/she carries out other tasks as requested in situations where hands-on intervention/participation may be required.

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