Medical Records Nurse

5 days ago

Milwaukee WI, United States Fresenius Medical Care Full time

Functions as part of the Home Therapies dialysis health care team. Ensures provision of quality home patient care in accordance with company policies, procedures and training. Supports the company’s commitment to the Quality Enhancement Program (QEP) and CQI activities, including those related to patient satisfaction. Actively participates in process improvement activities that enhance the likelihood that patients will achieve the company’s Quality Enhancement Goals (QEP).

Staff Related:
Provides safe and effective training and oversight of the delivery of home dialysis therapies to patients in compliance with standards outlined in the facility policy and procedure manuals, as well as regulations set forth by the Corporation, state and federal agencies.
Rotates with other licensed staff to ensure adequate coverage.
Participates in staff training and orientation of new staff as assigned.
Participates in all required staff meetings as scheduled.
Quality:
Provides outstanding quality of patient care, as defined by company quality goals and standards.
Submits CQI information to Clinical Manager for completion of HT QAI Template for inclusion in facility CQI packet.
Assists in the identification and evaluation of candidates for the company Home Therapies Program, including assessment of patients’ home environment.
Trains home patients and their families/significant others on the safe and effective operation and maintenance (as appropriate), of all home therapies equipment through a formal Home Therapies training program.
Assesses patient and family readiness and ability to perform dialysis treatments at home and patients’ home environment for suitability in the ongoing delivery of home dialysis therapy.
Provides ongoing education to patients regarding their renal dialysis, peritoneal or vascular access and home dialysis therapy, and other related health conditions.
Dialysis Treatment:
Provides safe and effective delivery of home therapy support care to patients with ESRD.
Assesses patients’ response to home dialysis treatment therapy by following predetermined protocols.
Reports adverse patient events at home or in the clinic as well as equipment and technology related problems to the Clinical/Home Therapies management and physician including the correct documentation of such events.
Coordinates the transfer of patients to the hemodialysis clinic when needed and appropriate.
Reviews, transcribes, and enters physician lab orders accurately into the Medical Information System.
Follows company policies and government regulations related to the collection, packaging, and delivery of lab specimens and reporting of results.
Maintains competency with all emergency operational procedures, and initiate CPR and emergency measures in the event of a cardiac and/or respiratory arrest when the patient is in the medical office.
Administers medications as prescribed including following algorithms (as appropriate), and document appropriate medical justification if indicated and maintain records on controlled substances as required by law.
Maintains appropriate skill level in the operation of all home dialysis therapy-related equipment, including the ability to troubleshoot equipment problems with the patient via telephone.
Directs patients in the preventative maintenance of home therapies equipment, including water systems and analyses as appropriate.
Coordinates with the company products division on the delivery, operation and maintenance of all home therapy dialysis equipment.
Medical Records & Documentation:
Admits all new patients and documents as needed.
Documents all relevant data including physician orders, lab results, vital signs, and treatment parameters, and patient status and any treatment related data appropriately, and enters into Medical Information System.
Participates in and ensures all company policies regarding patient admission, transfer, and discharge are appropriately implemented.
Completes all monthly and annual reporting as required by company policies and government regulations.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Day to day work includes desk and personal computer work and interaction with patients, facility staff and physicians. The position requires travel between assigned facilities and various locations within the community. Travel to regional, Business Unit and Corporate meetings may be required.
The work environment is characteristic of a health care facility with air temperature control and moderate noise
May be exposed to infectious and contagious diseases/materials
~ SUPERVISION:
~ Graduate of an accredited School of Nursing (R.Minimum of one year medical-surgical nursing experience preferred, ICU experience preferred.
Minimum of one year dialysis experience preferred, peritoneal experience preferred.
Successfully complete a training course in the theory and practice of dialysis therapies.
Competent at operating all Home Therapies related equipment.
Icd-9 coding Training.
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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