Medical Records Nurse

1 month ago


Salem OR, United States Fresenius Medical Care Full time

Willing to train or Training Provided
The professional registered nurse (CAP RN 2) position may be an entry level CAP designation for new employees that meet the CAP RN 2 criteria or attained through advancement by the CAP RN 1. The CAP RN 2 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.
As a member of the Chronic Kidney Disease (CKD) health care team, the CAP RN 2 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, Clinical Manager or Physician as needed.
Recognizes aspects and implications of patient status that vary from normal and reports to or collaborates with appropriate health team members for input.
Assesses daily assigned patient care needs and collaborates with direct and ancillary patient care staff as needed.
Directs and provides all aspects of the daily provision of safe and effective delivery of chronic hemodialysis therapy to assigned patients.
Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification and effectiveness.
Ensures correct laboratory collection, processing and shipping procedures are performed and reschedules missed or insufficient laboratory collections.
Ensures physician orders for assigned patients are entered and acknowledged in the Medical Record.
Delegates appropriate tasks to direct patient care staff including but not limited to LVN/LPNs and Patient Care Technicians.
Monitors patient care staff for appropriate techniques and adherence to FKC policy and procedures.
Promotes infection control, equipment and environmental safety.
Assesses, collaborates and documents patient/family's basic learning needs including direct and ancillary patient care staff to provide initial and ongoing education to patients and family.
Serves as a 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 . Provides feedback about new employee's progress to the CM and the Education Department using evaluation tools and direct communication.
Maintains direct supervision of the new employee until the employee is released to work independently by the Education Department and CM.
Encourages the new employee to function independently within the constraints of the training schedule and supplies positive feedback as well as suggestions to improve knowledge and skills.
Collaborates with the interdisciplinary team in the assessment and development of patient plans of care.
Identifies expected outcomes, documents and updates the nursing assessment and plan of care for assigned patients through collaboration with the Interdisciplinary Team.
Checks availability of adequate emergency equipment and supplies daily as assigned.
Serves as a resource for health care team, participates in staff training, orientation of new staff as assigned.
Participates in all required staff meetings as scheduled.
Provides education to staff members regarding updates to policy and procedures as directed by Supervisor.
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 and 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/LPNs as a Team Leader or designated Nurse in charge, after the following:
~Successful completion of all FKC education and training requirements for new employees plus
~Graduate of an accredited School of Nursing.
Entry level for RNs with 2 years or more of nephrology nursing experience within the last two years or BSN plus 1 year of nephrology nursing experience within the last two years.
Successful completion of FKC Education and Training requirements for new employees.
Successful completion of all annual required education/training/competencies.
Successful completion of on-going training and education as assigned or required.
 
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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