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Medical Records Nurse
3 months ago
Functions as part of the hemodialysis health care team as a Staff Registered Nurse to ensure provision of quality patient care on a daily basis in accordance with FMS policies, procedures, and training. Supports the FMCNA’s mission, vision, values, and customer service philosophy. Supports the FMCNA commitment to the Quality Enhancement Program (QEP) and CQI Activities, including those related to patient satisfaction and actively participates in process improvement activities that enhance the likelihood that patients will achieve the FMCNA Quality Enhancement Goals (QEP). Adheres to all requirements of the FMCNA Compliance Program, and FMS patient care and administrative policies.
Directs Patient Care Technician’s provision of safe and effective delivery of chronic hemodialysis therapy to patients in compliance with standards outlined in the facility policy procedure manuals, as well as regulations set forth by the corporation, state, and federal agencies.
Delegates tasks to all direct patient care staff including but not limited to LVN/LPNs, Patient Care Technicians, and Dialysis Assistants.
Assesses daily patient care needs and develops appropriate patient care assignments.
Routinely monitors patient care staff for appropriate techniques and adherence to facility policy and procedures.
Participates in staff training and orientation of new staff as assigned
Participates in all required staff meetings as scheduled.
Provides ongoing education to patients regarding their renal disease, vascular access and dialysis therapy, and other related health conditions.
Provides patient specific detailed education regarding adequacy measures where applicable - Online Clearance Monitoring (OLC), Adequacy Monitoring Program (AMP), Urea Kinetic Modeling (UKM).
Educates patients regarding laboratory values and the relationship to adequate dialysis therapy, compliance with treatment schedule, medications, and fluid.
Provides safe and effective delivery of care to patients with ESRD.
Accurately implements treatment prescriptions including Sodium (Na) modeling prescription, and Ultrafiltration modeling (where appropriate) to ensure stable treatment therapy as indicated.
Assesses patients’ response to hemodialysis treatment therapy, making appropriate adjustments and modifications to the treatment plan as indicated by the prescribing physician. Initiates Initial and Annual Nursing Assessment, and ongoing evaluation and documentation of patient care needs according to FMC Policies and Procedures.
Actively participates in the pre-evaluation, initiation, monitoring, termination, access homeostasis, and post evaluation of patients receiving hemodialysis treatment therapy according to established FMC procedures.
Provides, supervises (if applicable), and monitors hemodialysis access care according to established procedures.
Implements, administers, monitors, and documents patient's response to prescribed interdialytic transfusions, including appropriate notification of adverse reactions to physician and appropriate blood supplier.
Ensures accurate and complete documentation by Patient Care Technician on the Hemodialysis Treatment Sheet.
Reviews, transcribes, and enters physician lab orders accurately into the Medical Information System.
Ensures correct labs tubes are utilized for prescribed lab specimens and that lab draw and processing procedures are performed appropriately for all lab samples.
Identifies and ensures appropriate follow-through regarding missed labs and specimens reported to be insufficient according to company policies and procedures.
Ensures all specimens are appropriately packaged according to Department of Transportation (DOT) policies and procedures relating to shipment of blood or body fluid specimens and potentially hazardous material.
Enforces all company approved policies and procedures, as well as regulations set forth by state and federal agencies and departments.
Maintains overall shift operation in a safe, efficient, and effective manner.
Act as a resource for other staff members.
Routinely meets with the Clinical Manager to discuss personnel and patient care status, issues, and information.
Collaborate and communicate with physicians and other members of the healthcare team to interpret, adjust, and coordinate care provided to the patient.
Provides assistance as needed to patients regarding prescription refills according to FMCNA Policies.
Ensures all physician orders are transcribed and entered into the Medical Information system in a timely manner.
Maintains facility drug list for all required stock medications.
Maintains competency with all emergency operational procedures, and initiates CPR and emergency measures in the event of a cardiac and/or respiratory arrest.
Ensures verification and availability of adequate emergency equipment.
Ensures provision of appropriate vaccinations, immunizations, and annual Tuberculosis (TB) testing.
Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification if indicated.
Administers PRN medications as prescribed and completes appropriate documentation of assessment of effectiveness.
Ensures a clean, safe, and sanitary environment in the dialysis facility treatment area.
Ensures competency in the operation of all dialysis-related equipment safely and effectively.
Ensures that all blood spills are immediately addressed according to FMCNA Bloodborne Pathogen Control Policies.
Ensures all relevant data including physician orders, lab results, vital signs and treatment parameters, and patient status are documented appropriately and entered into Medical Information System.
Ensures all appropriate patient related treatment data is entered into the Medical Information System.
Ensures all FMCNA policies regarding patient admission, transfer, and discharge are appropriately implemented.
Ensures and verify accuracy of Patient Care Technician documentation.
Reviews and ensures appropriate daily completion of Hemodialysis Treatment Sheets by all patient care staff.
Ensures that all appropriate procedures are followed regarding opening and closing procedures, inclusive of monitoring that all staff and patients have safely left the premises.
Initiates, documents, and completes ongoing Continuous Quality Improvement (CQI) activities including monthly reports.
Ensures patient medical records are complete with appropriate information, documentation, and identification on each page (Addressograph label is on all chart forms).
Completes patient care plans for new patients within the initial 30 days or any patients deemed unstable requiring monthly patient care plans.
Completes initial and annual Nursing History and Assessment physical.
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 and 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.
SUPERVISION:
~ Graduate of an accredited School of Nursing.
Minimum of one-year medical-surgical nursing experience preferred.
ICU experience preferred.
Successfully complete a training course in the theory and practice of hemodialysis.
Provide coverage at any or all area facilities as required by management.
Icd-9 coding Training.
Nurses Technical Training.
~ 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.
Understands and conforms to the rules and regulations affecting the RN’s current area of practice including federal, state and local laws.
Accurately and completely report and document.
Care rendered.
Contacts other health care team members concerning significant events regarding client’s status.
Respect the client’s right to privacy by protecting confidential information unless obligated or allowed by law to disclose the information. Report unsafe nursing practice which a clinician has reasonable cause to suspect has exposed or is likely to expose a client unnecessarily to risk of harm as a result of failing to provide client care that conforms to the minimum standards of acceptable and prevailing professional practice. Ensures quality and safe delivery of OIC care service.
Practice is guided by policies, procedures and standards of clinical practice.
Understands and implements current standards of practice for infusion therapy.
Adheres to policies related to medication safety, including documentation of orders, correct administration, double check procedures and other established policies and practices.
Understands use of products and equipment.
Observes and monitors OSHA, infection control and safety policies.
Contributes to a safe and secure environment for patients, visitors and staff by following established procedures and protocols.
Accurately documents, implements and evaluates Physician orders in a timely manner.
Initiates teaching using patient teaching protocols and patient care standards.
Identifies expected outcomes and nursing interventions to meet identified diagnosis.
Implements nursing interventions to meet patient needs and changing conditions. Monitors patients for compliance with therapy.
Understands and respects nursing boundaries.
Shows kindness and care with patient/family. Maintains optimal drug and supply inventory and reports are submitted in a timely manner.
Ensures that the mixing area is clean, neat and orderly at all times.
Responsible for the accuracy of information recorded for proper patient billing.
Ensures that all purchasing invoices and inventory records are completed and submitted in a timely manner.
Participates in ongoing training and education.
Consistently addresses and communicates patient concerns to the Physician and OIC staff.
Completes job tasks on time by planning and organizing the schedule of activities.
Effectively communicates with Pharmacy for collaboration of protocols, patient care and Physician communication.
Communicates with OIC staff, Division Managers, Physicians and Corporate clinical as necessary.
Nursing calendar/ patient schedules reflects planned visits 2 weeks in advance.
Performs nursing functions in staffing situations.
Uses equipment and supplies effectively and efficiently. Monitors supplies to maintain appropriate inventory.
Accurately performs drug and supply inventory.
Nursing billing is accurate and timely.
Ensures a RN is available at all times during OIC office hours.
Ensures a RN is on call for emergencies involving patients 24 hours, if site not utilizing Healix Call Center
Monitors and maintains professional licensure and qualification of staff nursing.
Participates in case conferences and staff meetings.
Presents a positive image of the OIC at all times, and at professional functions, with patients, physicians, OIC staff, etc.
Assumes responsibility for improving care/services.
Monitors staff completion of assignments.
flexible in adjusting to a new or changing work environment/requirement.
Communicates with staff regarding assignments, as necessary.
Cooperates with staff members according to OIC philosophy and objectives.
Participates in establishing (written and instructing other staff) protocols for the initiation of new therapies or new care related programs.
Include the following basic performance factors all Healix, Inc. Understands and adheres to policies and procedures.
As a part of your job, you will receive protected health information. It is your responsibility to comply with HIPAA in using and disclosing health information.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
2 – 4 years related experience and/or training; One-year experience in Home Health Care or Home IV Therapy
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
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.
"The rate of pay for this position will depend on the successful candidate’s work location and qualifications, including relevant education, work experience, skills and competencies and may fall outside of the range shown.
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