Prepare, scan and verify documents into the medical record daily.
Audit resident records at admission, quarterly, and at discharge for completeness, accuracy, consistency, and timeliness within the required timeframe. Ensures that records requiring signatures are received and filed within the required timeframe.
Reports results, on a routine basis, of all audits to the Administrator, Director of Nursing, and MDS Coordinator.
Maintain resident medical information in chronological order, thinning or destroying records according to established procedures. Stores closed hard copy clinical records to ensure easy retrieval and sending records to offsite storage according to the requirements of retention as dictated by Corporate policy.
Maintains and controls disclosure of patient-identifiable information to authorized sources (persons) as outlined in HIC Quick
Reference Job Responsibilities (MPRO, Attorneys, Insurance Companies, Social Services, etc.)
Requests information from other agencies/parties concerning Facility’s Residents for medical record completeness, and as directed from Interdisciplinary Team.
Provides information to those involved in QAPI
Adhere to patient rights and maintain confidentiality in accordance with HIPPA guidelines.
Attend staff meetings and provide in-services as requested.
Order nursing supplies for basic patient care and special disposable equipment for treatments. Receive delivered supplies, transport, and stock in appropriate utility areas rotating using the “FIFO” method, (First in, First Out). Keep within budgetary standards and report expected over budget situations before placing orders. Code bills in compliance with AP protocols.
Regularly monitor shelves in primary and back-up storage areas to note unusual use or non- availability. Relay supply concerns to the Director of Nursing
Order and track special equipment. Return equipment to vendor when resident usage is complete.
Provide set-up and supplies for isolation and post-mortem care.
Schedule and accompany (or delegate to a CNA to accompany) residents for medical appointments when necessary.
Clean or delegate CNA’s to clean patient closets and bedside stands on a scheduled basis.
Sanitize and disinfect equipment according to nursing and infection control policies and procedures. Including feeding or PCA pumps and poles and return to storage location.
Monitor, clean, and organize utility and stock rooms daily.
Create and distribute monthly staffing schedules for Nurses and CNA’s. Monitor work schedule to ensure adequate staffing for unit within PPD range and fill open shifts as needed. Work the floor as a CNA when required.
Work in close partnership with HR to determine placement and orientation schedules for new nursing personnel. Notify appropriate mentors of said schedule.
Maintain ongoing communication with the supervisors and other management personnel regarding staffing and scheduling issues.
Respond to employee requests for vacation time and adjust schedule appropriately.
Provide staffing reports to DON and Administrator to aide in budget preparation.
Prepare, scan and verify documents into the medical record daily.
Audit resident records at admission, quarterly, and at discharge for completeness, accuracy, consistency, and timeliness within the required timeframe.
Ensures that records requiring signatures are received and filed within the required timeframe. Reports results, on a routine basis, of all audits to the Administrator, Director of Nursing, and MDS Coordinator.
Maintain resident medical information in chronological order, thinning or destroying records according to established procedures. Stores closed hard copy clinical records to ensure easy retrieval and sending records to offsite storage according to the requirements of retention as dictated by Corporate policy.
Maintains and controls disclosure of patient-identifiable information to authorized sources (persons) as outlined in HIC Quick Reference Job Responsibilities (MPRO, Attorneys, Insurance Companies, Social Services, etc.)
Requests information from other agencies/parties concerning Facility’s Residents for medical record completeness, and as directed from Interdisciplinary Team.
Adhere to patient rights and maintain confidentiality in accordance with HIPAA guidelines.
Attend staff meetings and provide in-services as requested.
Take labs to hospital when needed.
Tend to any and all medical records that come into the building.
Answer and transfer facility phone calls when needed.
Make sure all charts are complete, gather data if information is missing.
Assist with medical records requests.
Send corporate compliance reports out three times a week. Follow up with CCC and DON that all UOA’s doctor visits and orders are up to date.
Handle all aspects of visiting doctors (podiatry, dentist, audiology, and vision).
Order, stock, and maintain sufficient quantity of nursing supplies to permit provision of ordered and necessary nursing care.
Visit other Mission Point facilities or stores if supplies are needed and delivery is days away.
Perform other tasks as required.
