Medical Records Nurse

3 weeks ago

Colorado Springs CO, United States The Gardens Skilled Nursing Facility Full time

1500 SIGN ON BONUS \*\**_
The Gardens is looking for a full time *Day shift* and *Night shift* RN for 12 hour shifts. We are a small, family oriented 45 bed LTC facility located on the west side. Utilize the nursing process by demonstrating appropriate assessment, planning, implementation, and evaluation of the patient's care, as evidenced by client/staff observation.
* collect and document the patient's current health status and medical history. Complete and/or review Admission Data Record as defined by policy. nurse can input assessment and revise plan of care based on new data and patient's condition.
* Document accurate and ongoing assessment of patient status. Document patient care which reflects nursing intervention, patient response to care provided, patient needs, problems, capabilities, limitations, and progress toward goals.
* Documentation includes evidence of appropriate patient/significant other teaching, and the understanding of these instructions is noted in the medical record.
* Communicate with the physician regarding patient needs, the nursing assessments, and recommendations daily, and as needed, as evidenced by client feedback and Operations Coordinator observation.
Collaborate with other nurses and health team members to ensure the patient's well-being as evidenced by staff/client feedback.
* Administer medications according to policy and procedure.
* Administer IV's according to policy and procedure if certified and within scope of practice as designated by state
* Observe and document patient's response to pertinent medications.
* Demonstrate ability and appropriate technical skills when administering treatments and procedures in accordance with physician's orders and policy and procedure (done within a timely manner).
* Demonstrate necessary skills and knowledge to provide care for patients according to policy and procedure.
* Demonstrate necessary skills and knowledge to provide care for patients according to division/unit specific competencies.
* Perform indirect patient care, utilizing established procedures, policies, and standards as evidenced by client/staff feedback and Operations Coordinator observation.
* Give a thorough, concise report at change of shift.
* Accurately transcribe physician orders according to policy and procedure.
* Maintain a clean, neat, and safe environment for patient and staff according to policy and procedure as evidenced by staff/client feedback and Operations Coordinator observation.
* Ensure that supplies and equipment necessary for patient care are stored in an organized and efficient manner.
Adhere to Administrative System/Nursing Service policies as evidenced by Director of Nursing
* Comply with specific System/division/unit policy and procedure concerning safety.
* Attend a minimum of four staff meetings and read and sign all minutes of meetings not attended.
Job Types: Full-time, Part-time
00 per hour
Dental insurance
* Health insurance
* Standard shift:
* Day shift
Every weekend
Nursing: 1 year (Preferred)

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