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Medical Records Nurse

3 months ago

Waimea HI, United States Fresenius Medical Care Full time

PURPOSE AND SCOPE:
Functions as part of the hemodialysis health care team as a Staff Registered Nurse to ensure provision of quality patient care on a daily basis in accordance with FMS policies, procedures, and training. Supports the FMCNA's mission, vision, values, and customer service philosophy. Supports the FMCNA commitment to the Quality Enhancement Program (QEP) and CQI Activities, including those related to patient satisfaction and actively participates in process improvement activities that enhance the likelihood that patients will achieve the FMCNA Quality Enhancement Goals (QEP). Adheres to all requirements of the FMCNA Compliance Program, and FMS patient care and administrative policies.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
* Directs Patient Care Technician's provision of safe and effective delivery of chronic hemodialysis therapy to patients in compliance with standards outlined in the facility policy procedure manuals, as well as regulations set forth by the corporation, state, and federal agencies.
* Delegates tasks to all direct patient care staff including but not limited to LVN/LPNs, Patient Care Technicians, and Dialysis Assistants.
* Assesses daily patient care needs and develops appropriate patient care assignments.
* Routinely monitors patient care staff for appropriate techniques and adherence to facility policy and procedures.
* Participates in staff training and orientation of new staff as assigned
* Participates in all required staff meetings as scheduled.
* Ensures educational needs of patients and family are met regarding End Stage Renal Disease (ESRD).
* Provides ongoing education to patients regarding their renal disease, vascular access and dialysis therapy, and other related health conditions.
* Discusses with patient, and records education related to diet/fluid and medication compliance.
* Provides patient specific detailed education regarding adequacy measures where applicable - Online Clearance Monitoring (OLC), Adequacy Monitoring Program (AMP), Urea Kinetic Modeling (UKM).
* Ensures transplant awareness, modality awareness, and drive catheter reduction.
* Educates patients regarding laboratory values and the relationship to adequate dialysis therapy, compliance with treatment schedule, medications, and fluid.
* Provides safe and effective delivery of care to patients with ESRD.
* Accurately implements treatment prescriptions including Sodium (Na) modeling prescription, and Ultrafiltration modeling (where appropriate) to ensure stable treatment therapy as indicated.
* Assesses patients' response to hemodialysis treatment therapy, making appropriate adjustments and modifications to the treatment plan as indicated by the prescribing physician. Communicates problems or concerns to the Team Leader or physician.
* Identifies and communicates patient related issues to Team Leader or physician.
* Initiates Initial and Annual Nursing Assessment, and ongoing evaluation and documentation of patient care needs according to FMC Policies and Procedures.
* Actively participates in the pre-evaluation, initiation, monitoring, termination, access homeostasis, and post evaluation of patients receiving hemodialysis treatment therapy according to established FMC procedures.
* Takes appropriate intervention for changes in patient adequacy status and troubleshooting access flow issues as identified by OLC/AMP yellow lights.
* Provides, supervises (if applicable), and monitors hemodialysis access care according to established procedures.
* Implements, administers, monitors, and documents patient's response to prescribed interdialytic transfusions, including appropriate notification of adverse reactions to physician and appropriate blood supplier.
* Ensures accurate and complete documentation by Patient Care Technician on the Hemodialysis Treatment Sheet.
* Reviews, transcribes, and enters physician lab orders accurately into the Medical Information System.
* Ensures appropriate preparation of lab requisitions for Spectra or alternate lab.
* Ensures correct labs tubes are utilized for prescribed lab specimens and that lab draw and processing procedures are performed appropriately for all lab samples.
* Identifies and ensures appropriate follow-through regarding missed labs and specimens reported to be insufficient according to company policies and procedures.
* Ensures all specimens are appropriately packaged according to Department of Transportation (DOT) policies and procedures relating to shipment of blood or body fluid specimens and potentially hazardous material.
* Ensures that all labs are directed and delivered to appropriate labs.
* Reports alert/panic and abnormal labs results to appropriate physician.
* Ensures lab results are forwarded to physicians as requested.
* Enforces all company approved policies and procedures, as well as regulations set forth by state and federal agencies and departments.
* Maintains overall shift operation in a safe, efficient, and effective manner.
* Act as a resource for other staff members.
* Routinely meets with the Clinical Manager to discuss personnel and patient care status, issues, and information.
* Collaborate and communicate with physicians and other members of the healthcare team to interpret, adjust, and coordinate care provided to the patient.
* Provides assistance as needed to patients regarding prescription refills according to FMCNA Policies.
* Ensures all physician orders are transcribed and entered into the Medical Information system in a timely manner.
* Oversees all documentation of patient information.
* Maintains facility drug list for all required stock medications.
* Maintains competency with all emergency operational procedures, and initiates CPR and emergency measures in the event of a cardiac and/or respiratory arrest.
* Ensures verification and availability of adequate emergency equipment.
* Ensures provision of appropriate vaccinations, immunizations, and annual Tuberculosis (TB) testing.
* Administers medications as prescribed or in accordance with approved algorithm(s), and documents appropriate medical justification if indicated.
* Administers PRN medications as prescribed and completes appropriate documentation of assessment of effectiveness.
* Maintains appropriate recording of controlled substances as required by law.
* Assists with the coordination of patient transportation if necessary.
* Ensures a clean, safe, and sanitary environment in the dialysis facility treatment area.
* Ensures competency in the operation of all dialysis-related equipment safely and effectively.
* Ensures all patient stations, including machines and chairs, are clean and free of blood and placed appropriately.
* Ensures that all blood spills are immediately addressed according to FMCNA Bloodborne Pathogen Control Policies.
* Ensures all relevant data including physician orders, lab results, vital signs and treatment parameters, and patient status are documented appropriately and entered into Medical Information System.
* Ensures all appropriate patient related treatment data is entered into the Medical Information System.
* Ensures all FMCNA policies regarding patient admission, transfer, and discharge are appropriately implemented.
* Ensures and verify accuracy of Patient Care Technician documentation.
* Reviews and ensures appropriate daily completion of Hemodialysis Treatment Sheets by all patient care staff.
* Ensures that all appropriate procedures are followed regarding opening and closing procedures, inclusive of monitoring that all staff and patients have safely left the premises.
* Initiates, documents, and completes ongoing Continuous Quality Improvement (CQI) activities including monthly reports.
* Completes monthly nurses' progress note.
* Ensures patient medical records are complete with appropriate information, documentation, and identification on each page (Addressograph label is on all chart forms).
* Reviews transplant status and follows established procedure regarding appropriate action to be taken.
* Completes patient care plans for new patients within the initial 30 days or any patients deemed unstable requiring monthly patient care plans.
* Completes any long-term programs that are due.
* Completes initial and annual Nursing History and Assessment physical.
* Ensures completion of Annual Standing Order Review with each physician as required.
* Performs additional duties as assigned.
PHYSICAL DEMANDS AND WORKING CONDITIONS :
The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. 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. This position requires frequent, prolonged periods of standing and the employee must be able to bend over. 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. up as high as 5 feet.
* 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.
* Employees are required to take the Ishihara's Color Blindness test as a condition of employment. Note that: Failing the Ishihara Test for Color Blindness does not preclude employment. The Company will consider whether reason
* able accommodation can be made.
SUPERVISION:
* None
EDUCATION AND REQUIRED CREDENTIALS:
* Graduate of an accredited School of Nursing.
* Current appropriate state licensure.
* Must meet the practice requirements in the state in which he or she is employed.
EXPERIENCE AND SKILLS :
* Minimum of one-year medical-surgical nursing experience preferred.
* Hemodialysis experience preferred.
* ICU experience preferred.
* Successfully complete a training course in the theory and practice of hemodialysis.
* Successfully complete CPR Certification.
* Employees have to meet the necessary requirements of Ishihara's Color Blindness test as a condition of employment.
* Provide coverage at any or all area facilities as required by management.
* Icd-9 coding Training.
* Nurses Technical Training.
* Must meet appropriate state requirements (if any).
EO/AA Employer: 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.
"The rate of pay for this position will depend on the successful candidate's work location and qualifications, including relevant education, work experience, skills and competencies and may fall outside of the range shown.
Hourly Rate: $36.00 - $60.00"