Clinical Documentation Nurse Educator
Job Posting for Clinical Documentation Nurse Educator at the Chickasaw Nation
Description
We are currently looking for a Full Time Clinical Documentation Nurse Educator to join our Area of Nursing Learning and Development team located at the Chickasaw Nation Medical Center.
Summary:
This position is located with the Department of Health at the Chickasaw Nation Medical Center. The facility provides professional and clinical health care services to Native American beneficiaries. The Clinical Documentation Nurse Educator provides clinically based concurrent and retrospective review of inpatient and/or ambulatory clinics medical records to evaluate nurse documentation ensuring adequate documentation was obtained. The registered nurse (RN) collaborates extensively with all nursing staff, and or designated patient caregivers, to ensure an accurate reflection of the patient’s acuity, nursing diagnosis, and nursing interventions are reflected suitably within the Electronic Medical Record (EMR). The Clinical Documentation Nurse Educator will educate to nursing staff the importance of appropriate nursing documentation of the plan of care accurately reflecting assessment, planning, implementation, and evaluation of care.
- Provides and advocates age and culturally appropriate, holistic patient care based upon facility mission statements and as outlined in policies and procedures
- Works with program leadership to plan, develop, and implement clinical documentation education programs for all inpatient and outpatient nursing staff
- Educates nursing staff regarding documentation goals, objectives, regulatory compliance, procedures, and the need for accurate and complete documentation in the health record
- Maintains confidentiality, security, and integrity of data and information
- Participates in meetings to ensure effective communication with staff, peers, supervisors and management
- Tracks, logs and maintains all training activity, such as scheduling classes, tracking attendance, rating performance, collecting feedback and evaluating effectiveness of training program
- Assists with orientation, special activities and training on specific procedures, tasks or equipment
- Provides first class customer service - courteous and helpful to all internal and external customer types
- Greets and engages with a smile
- Determines and meets needs
- Seeks positive experience and outcomes
- Answers questions in a courteous and professional manner
- Partners with internal and external services as needed to ensure appropriate referral is made
- Completes all training and development requirements and participates in continuing education opportunities
- Works in a collaborative and supportive manner to support the productivity and safety of the work area, team members and customers of all types
- Shares responsibilities for maintaining adequate supplies and equipment
- Maintains general upkeep of work area and maintains a safe environment
- Observes and addresses potential environmental hazards and risks
- Maintains and promotes professionalism
- Punctual and consistent in meeting start time, work schedule, attendance and other assigned work time metrics
- Adheres to Chickasaw Nation dress code standards
- May provide break coverage for others as assigned
- May augment staff in other areas as needed based on staffing and needs ratio in regularly assigned unit
- Maintain knowledge of and follow all laws, rules, regulations, policies and SOPs for assigned area, e.g. MICS, TICS, hospital standards, health codes, food sanitation, accounting principles, etc.
- All other duties as assigned
Competencies:
Essential:
- Follow instructions, written or oral
- Adhere to all scheduling and attendance requirements
- Honesty, truthfulness, reliability, accountability
- Read, understand and apply regulations and policies
- Knowledge of industry best practices
- Ability to remain calm under stress
- Communicates verbally with team, departments, guests and management
Skills:
Essential:
- Basic Computer skills
- Electronic health record software as appropriate
- Must be familiar with the MS Office Suite of products
Experience:
Essential:
- 3 years directly related experience
Education:
Essential:
- Bachelors of Nursing
Nonessential:
- Masters of Nursing
Credentials:
Essential:
- Unrestricted Oklahoma Registered Nurse License
- Basic Life Support
- Advanced Cardiovascular Life Support
- Pediatric Advanced Life Support
Working Conditions:
Essential:
- Hospital or Clinic
- Standing up to 100% of shift
- Walk up to 100% of shift
- Sometimes bend, kneel, stoop, push, reach
- Sometimes lift and or carry up to 50 lbs
- Potential exposure to contagious diseases
- May be required to assist individuals who are emotionally disturbed
- May work evening shift
- May work weekend shift
- Pass pre-employment drug test
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