Medical Records Nurse

6 days ago

Acton ME, United States Fresenius Medical Care Full time

The professional registered nurse Outpatient RN CAP 1 is an entry level designation into the Clinical Advancement Program (CAP). This position is accountable and responsible for the provision and coordination of clinically competent care including assessment, planning, intervention and evaluation for an assigned group of patients. This may include delegation of appropriate tasks to direct patient care staff including but not limited to RNs, LVN/LPNs and Patient Care Technicians. As a member of the End Stage Kidney Disease (ESKD) health care team, this position participates in decision-making, teaching, leadership functions, and quality improvement activities that enhance patient care outcomes and facility operations.
All duties and responsibilities are expected to be performed in accordance with Fresenius Kidney Care policy, procedures, standards of nursing practice, state and federal regulations.
* Performs ongoing, systematic collection and analysis of patient data pre - during - post hemodialysis treatment for assigned patients and documents in the patient medical record, makes adjustments or modifications to treatment plan as indicated and notifies Team Leader, Charge Nurse, Supervisor or Physician as needed.
* Assesses, collaborates, and documents patient/family's basic learning needs to provide initial and ongoing education to patients and family.
* Directs and provides, in collaboration with direct and ancillary patient care staff, all aspects of the daily provision of safe and effective delivery of hemodialysis therapy to assigned patients.
* Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness.
* Serves as a resource for health care team, participates in staff training and orientation of new staff as assigned.
* Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections.
* Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team.
* Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
* The position provides direct patient care that regularly involves heavy lifting, moving of patients and assisting with ambulation. Equipment aids and/or coworkers may provide assistance.
* The employee may occasionally be required to move, with assistance, machines and equipment of up to 200 lbs., and may lift chemical and water solutions of up to 30 lbs. The work environment is characteristic of a health care facility with air temperature control and moderate noise levels.
* May be exposed to infectious and contagious diseases/materials.
* Day to day work includes desk work, computer work, interaction with patients, facility/hospital staff and physicians.
* The position may require travel to training sites or other facilities.
* Assigned oversight of Patient Care Technicians/LPNs/LVNs/RNs as a Team Leader or designated Nurse in Charge, after meeting all the following:
* Successful completion of all FKC education and training requirements for new employees.
* Graduate of an accredited School of Nursing.
* Entry level for RNs with less than 1 year of Nephrology Nursing experience in the last two years as a RN.
* Furthermore, I understand that the duties and responsibilities listed in this job description are intended only as illustrations of the various types of work that may be performed. If I have any questions about duties and responsibilities not specified in this job description that I am asked to perform, I should discuss them with my immediate Supervisor or my Human Resources representative.
Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity
Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.
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