Nurse - Medical Records

Who You Are

Are you a Registered Nurse or Licensed Practical Nurse with excellent clinical skills? Are you a confident as a healthcare professional and value the opportunity to develop relationships with your co-workers and the patients under your care? Are you looking for a job offering opportunities for growth and variety? Do you want a job that’s more than just a job – it’s also a future?

This position will be responsible for admission processes including:

• Entering transfer and ancillary orders
• Greeting residents upon arrival
• Showing residents to there rooms and giving them a general orientation of the facility
• Administering initial pain medications or insulin if applicable
• Complete head to toe assessment and document vitals including: height and weight
• Send orders and scripts to pharmacy report
• Review discharge orders with the resident
• Complete all discharge assessments/paperwork, complete documentation and prepare chart

This position will also be responsible for medical records processes including:

• 
  Organizing admission chart
• Auditing charts for completion
• Adding diagnoses codes to PCC
• Updating MD progress notes
• Checking UDA reports
• Keeping order review dates accurate for each month
• Running all medical records requests
• Keeping current and organized medical records charts in MR room

*May be pulled to work on the floor or to pass medications in the event of a call off*

Apply if you are:

• A licensed nurse in the State of Indiana
• Passionate about serving others
• Professional in appearance and behavior
• Able to work with a dedicated team

General:

1. Currently licensed and registered to practice as a professional nurse in the State of Indiana.

2. Successfully complete pre-employment process and screening.

3. Pass the physical examination given in behalf of gainful employment within the facility.

4. Professional manner and appearance.

Job Knowledge:

1. Nursing policies and procedures.

2. Administration of medication, possible side effects, treatment administration, local, state, and federal laws and regulations pertaining to resident care.

3. Comprehensive knowledge of nursing practices.

4. Physical, psychological, social and medical needs of residents.

5. Organizational structure and duties of employees under supervision of unit manager.

Other:

1. Competent in supervision and leadership.

2. Caring attitude.

3. Observant.

4. Foster and maintain a good working relationship with other staff.

5. Good judgement and emotional stability.

6. Ability to follow written and verbal instructions.

EXPOSURE CATEGORY I: Tasks that involve exposure to blood, body fluids, or tissues.

RN or LPN