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Medical Records Nurse

3 months ago

Wilmington DE, United States Cadia Healthcare Pike Creek Full time

Cadia Healthcare is a leading provider of skilled nursing and rehabilitation in your area. Cadia rewards it’s employees for their hard work and dedication to providing the best care possible, with a wide-range of benefits and perks to show we care.
Affordable Medical, Dental, and Vision Benefits for You & Your Family
401k Retirement With Company Match
Flexible Spending Accounts (FSA) & Health Reimbursement Accounts (HRA)
Paid Time Off - Vacation, Personal, Sick Days & Paid Holidays
Short-term Disability and Maternity Leave Options, Personal and Family Medical Leave
Company provided Life and Long Term Disability Coverage
Tuition Reimbursement
In Facility Training/Inservice Programs
Employee Assistance Program
Optional Legal & Identity Protection Services
RNs are central to our facilities and their skills are vital to the care we provide, making a difference in patients’ lives every day. Cadia is dedicated to providing the best care possible. Whether you are a new RN or seasoned, come join our accomplished staff of medical professionals
Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations & guidelines that govern the long-term care facility. Meet with your assigned nursing assistants to give a Nursing Report on assigned residents and review 24-hour summary report in the electronic medical record on assigned residents.
Assist in completing nursing assignments when necessary and make rounds on assigned residents throughout shifts. Admit, transfer, & discharge residents as assigned.
Complete all documentation as necessary for resident incidents & investigations. Notify the residents provider & next of kin when the resident is involved in an accident or incident or if there is a change in condition.
Ensure all medications & treatments have been administered and signed off prior to the end of the assigned shift and update the Nursing Supervisor on resident changes in condition. Receive telephone orders from physicians, transcribe orders & record in the electronic health record and prepare & administer medications & treatments as ordered by the provider.
Inform nursing staff of new admissions, their expected time of arrival, room assignment, etc. and ensure that rooms are ready for new admissions, greet newly admitted residents, and escort them to their rooms.
Ensure that nursing documentation reflects that the care plan is being followed when administering nursing care or treatment and review care plans for appropriate resident goals, problems, approaches & revisions based on nursing needs. Update care plans as appropriate.
Registered Nurse with a current state nursing license.
Previous long-term care experience is desirable.