The ideal candidate will have a CNA certificate and experience in Skilled Nursing. Nursing students are also preferred. 

POSITION:

The purpose of your position is to assist the Nurse Supervisor/Charge Nurse in their day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records, and as may be required by the Director of Nursing Services, to ensure that our medical records are maintained in an informative and descriptive manner.

QUALIFICATIONS/REQUIREMENTS:

• Sufficient education to demonstrate functional literacy
• Skilled in following written and verbal directions
• Experienced in effective interaction with individuals who are cognitively and/or physically impaired

ESSENTIAL JOB FUNCTIONS:

• Maintain an up-to-date roster of residents for your assigned unit.
• Answer telephones, direct calls, deliver messages to residents, etc.
• Maintain current listing of emergency phone numbers for your assigned unit.
• Maintain and forward daily tardy and absentee reports.
• Record appropriate resident identification data on designated medical records, wristbands.
• Forward new diet orders and/or diet changes to the Dietary Supervisor.
• Keep nursing service personnel informed of resident’s appointments.
• Assist in arranging for and making resident appointments for diagnostic and therapeutic services.
• Assist in arranging for transportation.
• Complete necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
• Forward completed charts of discharged residents to the Medical Records Department.
• Order lab/xrays and call for results.
• Assist the Nurse Supervisor/Charge Nurse in developing work assignments, and schedules.
• Inform nursing service personnel of new admissions, their expected time of arrival, room assignments, etc.
• Assist as necessary in the orientation of newly assigned personnel to your unit.
• Attend and participate in continuing educational programs designed to keep you abreast of changes in your profession.
• Participate in appropriate in-service training programs prior to performing tasks that involve potential exposure to blood/body fluids.
• Participate in all fire safety and disaster preparedness drills in a safe and professional manner.
• Follow infection control guidelines.
• Report all allegations of resident abuse and/or misappropriation of resident property.
• Comply with resident rights ensuring that all residents are treated fairly, with kindness, dignity, and respect.
• Must function as a team member and have flexibility.
• Must possess the ability to make independent decisions when circumstances warrant such action.
• Possess the ability to deal tactfully and harmoniously with personnel, residents and all visitors.
• Shows dependability by being punctual; maintains consistent attendance.
• Maintain the confidentiality of all resident care information.

ASSOCIATED FUNCTIONS:

• Record medical and administrative information in accordance with our established charting and documentation policies and procedures.
• Maintain the Daily Census Report and submit to Nurse Supervisor/Charge Nurse.
• Record vital signs as directed.
• Transfer residents.
• Pack residents’ belongings.
• Escort residents to discharge/transfer area, loading, etc.
• Direct visitors to resident rooms, office areas, etc.
• Attend various committee meetings of the facility.
• Implement recommendations from established committees
• Assist in the orientation of newly assigned personnel.
• Interpret department policies and procedures to personnel, residents, and visitors.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments in the facility.
• Greet newly admitted residents upon admission. Escort to room as necessary.
• Assist in escorting residents to/from activity and social functions.
• Encourage attending physicians to record and sign progress notes, physicians’ orders, etc. in accordance with current regulations.
• Report administrative problem areas to the Director. Assist in developing and implementing corrective action.
• Call funeral homes when requested by the family.
• Attend in-service training programs.
• Follow established safety regulations in the use of equipment and supplies.
• Assist in maintaining nursing service work areas in a clean and sanitary manner.
• Report hazardous conditions or equipment to the Nurse Supervisor/Charge Nurse.
• Inform the Nurse Supervisor/Charge Nurse of your equipment and supply needs.
• Follow established preventive maintenance procedures for maintaining your equipment and supplies.