Medical Records Nurse

4 weeks ago


Sacramento CA, United States Fair Oaks Recovery Center Full time

Per Diem
Shifts: AM (7am-7:30pm) and NOC (7pm-7:30am)
Salary: $50-55 per hour depending on experience
The Registered Nurse is responsible for providing nursing care to patients. Supervising care treatment and services of patient care provided by LPNs, CNAs and other staff on assigned unit and shift. Developing, implementing, and evaluating an individual plan of care for each client. Provides and coordinates care by assessing physical and behavioral health needs of client, develops and implements nursing care plans, maintains medical records and educates clients and their families about various physical and behavioral health conditions while ensuring client safety at all times.
* Assesses client’s status on an ongoing basis and pertinent information gathered is documented.
* Ensures nursing treatment plans are specific to assessed needs and initial treatment plan is completed upon admission.
* Takes physician’s orders (verbal or via telephone) accurately and documents appropriately; Ensures physician’s orders are legible if taken verbally and transcribed appropriately per policy and procedure.
* Accurately administers medications per ordered note and documents accurate count of controlled substance. Adjusts medications under provider’s supervision as needed; Notifies physician of significant changes in status such as difficulties with detox, medical emergency or change in medical status regarding response to medications, etc.
* Supervises self-administration of medications using safety initiative of using two means of client identification: documents and reports effects of scheduled and PRN medications.
* nurses, therapists, program managers, physician) regarding client care. Attends and participates in the unit activities such as therapy groups, family meetings as appropriate, staffing, unit meetings, etc.
* Provides education/explanation to clients, families, and co-workers regarding medication usage/maintenance, common side effects, client's rights, as well as other topics necessary for optimal client care.
* Assures thorough, accurate documentation is completed for all clients on each shift and client assignment sheets are completed daily and tasks are carried out as assigned.
* Gives thorough report to oncoming staff, supervisors, and physician.
* Graduation from an approved/accredited school of nursing.
* One or more years’ nursing experience within clinical area of service provided by facility preferred.
* Experience in behavioral health/psychiatric/addiction recovery environment preferred.
Certified in Psychiatric Nursing preferred.
Graduation from an approved/accredited school of nursing.
* One or more years’ nursing experience within clinical area of service provided by facility preferred.
* Experience in behavioral health/psychiatric/addiction recovery environment preferred.
Certified in Psychiatric Nursing preferred.
Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.
Job Type: Part-time
00 per hour


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