Medical Records Nurse

3 weeks ago

freeburg, United States Bethesda Health Full time
Bethesda Brings out the Best in Talented, Caring People At Bethesda, more than 1,200 employees dedicate their careers to improving the lives of others. As a team member at Bethesda, you'll enjoy great benefits such as: 403b, daily pay, bonuses, career advancement opportunities, and holiday pay. Medical, dental, vision, prescription, and life insurance available for regular status full and part time employees. Summary Accurately assesses residents' health status as well as their educational and environmental needs on admission and on an ongoing basis. Remains aware about and communicates to the appropriate interdisciplinary team (IDT) member any significant change in condition. Accurately documents all assessments. Develops dynamic care plans based upon the identified needs of the residents through an interdisciplinary approach that includes physicians, residents, families, and other IDT members. Reviews and revises the care plan as the resident's needs, problems, and goals change. Communicates the plan to the appropriate IDT members along with the residents and families. Accurately documents the care plan on admission, cognition change, or regulatory requirements for care planning. Identifies necessary nursing interventions relevant to the plan of care which includes nursing orders, physician orders, residents/families educational and environmental needs. Interventions such as medication administration, treatments, and IV fluid administrations are accomplished in a safe and timely manner. Documents all interventions accurately and timely. Uses critical thinking skills when dealing with residents' change in condition. Notifies the physician timely using the SBARR as the communication tool. Maintains composure during and handles any crisis situation such as family dissatisfaction, staff disputes, or inclement weather in a calm and professional manner. Monitors the care of the residents closely to see that the care plan is being delivered effectively. Identifies problem areas and uses the QAPI process to actively address the situation for immediate problem resolution. Remains knowledgeable about the status of the resident to quickly identify behavioral changes or other untoward signs or symptoms. Assists in answering call lights and assists with resident care such as ADLs. Completes twelve hours, at a minimum, of offerings related to nursing. Upholds commitment to remaining current in best nursing practices through knowledge of Bethesda's policies and self-study. May be assigned other duties as appropriate. Job Qualifications Education from an accredited school of nursing that results in becoming a registered nurse Current RN license in the state you will be working CPR/AED certification required, or willing to obtain within six months of employment Long-term care experience preferred Must possess critical thinking skills Excellent communication skills to interact verbally with patients, visitors, and staff Excellent time management and organizational skills Ability to stand and walk for long periods of time Ability to lift heavy objects using proper lifting techniques and with assistance as necessary Ability to transfer and move patients who vary with ability to assist weighing 200+lbs using proper lifting techniques and with assistance when necessary Ability to push and pull equipment weighing in excess of 40lbs using proper techniques and with assistance when necessary Manual dexterity, coordination and skillful use of hands when working with patients and equipment Visual acuity with the ability to distinguish color Ability to physically perform necessary documentation electronically and in writing Category: RN
Keywords: Registered Nurse, healthcare, patient care, nursing, care plans, interdisciplinary team, critical thinking, long-term care, documentation, medication administration

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