Medical Records Nurse

4 months ago


Temecula CA, United States Aveanna Healthcare Full time

Registered Nurse (RN) is responsible for providing and documenting skilled nursing care in accordance with the developed care plan and physicians orders for each individual patient while adhering to confidentiality standards and professional boundaries at all times.
Responsible for the delivery and coordination of quality patient care in compliance with physician orders.
• Continuously observes and assesses patient condition and care needs and reports changes in condition to the supervisor and/or physician as appropriate.
• Documents all activities, assessments, nursing actions, responses and coordination of care in a timely manner whenever care is delivered.
• Develop, implement and update the nursing care plan.
• Takes appropriate nursing action based on assessment and achieves expected outcomes.
• Recognizes changes in patient needs and responses requiring intervention and implements care to prevent risk or reduce risk.
• Accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act.
• Provide care utilizing infection control measures that protect both the staff and the patient according to OSHA standards.
• Educates the patient and family regarding the disease process, self-care techniques, and prevention strategies, and in meeting the patient’s nursing needs.
• Maintain knowledge of competencies related to the nursing profession by participating in educational programs, continued education units, internal learning management skills and skill evaluations.
Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing
• Demonstrated proficiency in clinical assessments, documentation and compliance with nursing care and policies and procedures
• One (1) year of experience required working under current nursing license
• Six (6) months of recent experience as a Licensed Nurse in a clinical care setting
• Home health experience
Must be able to speak, write, read and understand English
• Must be able to travel
• Must have visual and hearing acuity
• Must be able to sufficiently reposition patients and move equipment without assistance
• Possible exposure to blood, bodily fluids and infectious diseases
Equal Employment Opportunity and Affirmative Action: Aveanna provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Aveanna complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.
CCPA Notice for Job Applicants, Contractors, and Employees Residing in California
Registered Nurse (RN) is responsible for providing and documenting skilled nursing care in accordance with the developed care plan and physicians orders for each individual patient while adhering to confidentiality standards and professional boundaries at all times.
Responsible for the delivery and coordination of quality patient care in compliance with physician orders.
• Continuously observes and assesses patient condition and care needs and reports changes in condition to the supervisor and/or physician as appropriate.
• Documents all activities, assessments, nursing actions, responses and coordination of care in a timely manner whenever care is delivered.
• Develop, implement and update the nursing care plan.
• Takes appropriate nursing action based on assessment and achieves expected outcomes.
• Recognizes changes in patient needs and responses requiring intervention and implements care to prevent risk or reduce risk.
• Accepts responsibility for personal and professional accountability by complying with Aveanna policies, state and federal regulations, accrediting bodies and the Nurse Practice Act.
• Provide care utilizing infection control measures that protect both the staff and the patient according to OSHA standards.
• Educates the patient and family regarding the disease process, self-care techniques, and prevention strategies, and in meeting the patient’s nursing needs.
• Maintain knowledge of competencies related to the nursing profession by participating in educational programs, continued education units, internal learning management skills and skill evaluations.
Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing
• Demonstrated proficiency in clinical assessments, documentation and compliance with nursing care and policies and procedures
South Carolina – One (1) year of pediatrics experience
• California – One (1) year of experience required working under current nursing license
• Medical Oncology RN - 2 years Registered Nurse experience with cardiac monitoring and oncology experience
• Ambulatory RN - 2 years experience with vital assessment, plan of care development, and telephone triage
• Medical Surgical RN - 2 years Registered Nurse experience
• Peri-Operative Care RN - 2 years of Registered Nurse, preferably with oncology experience
Six (6) months of recent experience as a Licensed Nurse in a clinical care setting
• Home health experience
Must be able to speak, write, read and understand English
• Must be able to travel
• Must have visual and hearing acuity
• Must be able to sufficiently reposition patients and move equipment without assistance
• Possible exposure to blood, bodily fluids and infectious diseases
As an employer accepting Medicare and Medicaid funds, employees must comply with all health-related requirements in all relevant jurisdictions, including required vaccinations and testing, subject to exemptions for medical or religious reasons as appropriate.


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