Medical Records Nurse

1 month ago

Greensboro NC, United States Fresenius Medical Care Full time

The professional registered nurse Outpatient RN CAP 2 may be an entry level designation into the Clinical Advancement Program (CAP) for new employees who meet the RN CAP 2 criteria or attained through advancement from RN CAP 1. 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, leader, coach, mentor and role model for new and incumbent employees by setting examples of appropriate behavior, work habits and attitudes towards patients, co-workers, supervisors and the company at the facility, and area level. 
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.
Participates in education and quality improvement projects at the facility and area level as directed by Supervisor.
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 and 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//LVN/LPNs/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 minimum of 2 years of Nephrology Nursing experience


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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