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Medical Records Nurse

3 months ago

Manchester TN, United States Manchester Center for Rehabilitation and Healing Full time

Performs required skills (assessment, intervention) according to guidelines, policies and procedures.
Participates in interdisciplinary committees which influence or determine policies affecting nursing practice.
Follow facility procedures/protocols for admitting residents transferring to hospitals/clinics/outpatient visits and completion of appropriate documentation based on established guideline.
Makes rounds on all resident rooms and ensure that the L.s and/or others under his/her supervision receive their resident reports, has their assignments and break times scheduled.
N. in establishing routines which facilitate a high level of nursing practice.
Receives and give reports from and to outgoing and incoming shifts. Count or ensure the counting of controlled drugs with outgoing and incoming shifts.
Complete MDS Booklet as per schedule (Nursing Sections).
Develops care plan that demonstrate knowledge of criteria to ascertain resident specific needs based on health care problem(s).
Makes needed revisions and updates to the care plans.
Ensures that care plan is carried out which demonstrates familiarity with criteria to establish priorities specific to anticipated outcomes.
Monitors the provision of care for the residents in his/her assigned unit.
Interprets philosophy and objectives of nursing service to residents, families and others.
Identifies resident/family learning needs based on the discharge care plan as applicable and carries out appropriate teaching required.
Demonstrates ability to coordinate and collaborate with resident/family and other members of the comprehensive health care team.
Notifies physicians of pertinent observations and reactions, incident and abnormal laboratory and x-ray results as required and documents same promptly.
Reports all resident, visitor and work-related accidents/injuries and demonstrates appropriate follow through by investigating, documenting and processing incident reports.
Accepts guidance, supervision, and criticism if needed.
Practices in compliance with the Nurse Practice Act and regulatory agencies regulations.
Assures that a stock level of medications, medical supplies, equipment, etc. Assume the authority, responsibility and accountability of directing your nursing shifts.
Other responsibilities as deemed necessary and appropriate or as may be directed by the Director of Nursing Services or Administrator.
Graduate of an accredited School of Nursing
Nursing Experience which one has acquired clinical competence and strong leadership skills.
Shift Needs:
Part-Time ( All Shifts)