Medical Records Nurse

1 day ago

imperial, United States Bethesda Health Full time

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.
Full-time RNs can earn up to $6,000 Sign-on Bonus.
Accurately assesses residents' health status as well as their educational and environmental needs on admission and on an ongoing basis. 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. Documents all interventions accurately and timely. Uses critical thinking skills when dealing with residents' change in condition. 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. Education from an accredited school of nursing that results in becoming a registered nurse
Long-term care experience preferred
Excellent communication skills to interact verbally with patients, visitors, and staff
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
Registered Nurse (RN) at Bethesda Health summary:
As a Registered Nurse (RN) at Bethesda, I am dedicated to improving the health and lives of residents through comprehensive assessments, dynamic care planning, and collaboration with interdisciplinary team members. I ensure the timely and accurate documentation of all medical interventions and remain committed to ongoing education and best practices in nursing. My role includes monitoring residents' conditions, managing crises, and ensuring all care needs are met effectively and compassionately.
Registered Nurse, patient care, health assessment, care planning, nursing interventions, interdisciplinary team, critical thinking, healthcare, long-term care, clinical documentation

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