Job Summary: Provides indirect resident care in the facility. Meets the communication needs of the resident, family and staff. Prepares and compiles records in the facility. Maintains regulatory agency requirements, nursing and facility policies and procedures and standards.

DUTIES AND RESPONSIBILITIES:

Demonstrates Competency in the Following Areas:

• Prepares medical records for discharged residents and new admissions. Maintains medical records.
• Enters photo into EMR upon admission and as requested for updates
• Updates Resident name on room, end of bed, & closet upon admission and with any room changes
• Prepares new admission chart per admission checklist, ensure forms are properly labeled with residents name, physician and Medical Record Number
• Completes Admission Review and Checklist 7 days post admission – File findings with DON - 
• Prepares Discharge packet per Discharge Checklist
• Maintains current physician rounds listing, Podiatry, Dental and Opthomology visits listings
• Ensure Death Certificates are completed timely by physician
• Upload and maintain current PRI/Screen/POA and HCP within EMR
• Orders Supplies - Nunns Hospital Supply - Oxygen, Tube feeding
• Obtains requested items from Clinical Laboratory, Central Service, Pharmacy or other departments.
• Communicates appropriately and clearly to nurse manager, team leader, co-workers and physicians.
• Consults other departments, as appropriate, to provide for an interdisciplinary approach to the resident’s needs.
• Purging of charts on a routine basis (** How often))) according to checklist.
• Demonstrates an ability to be flexible, organized and function under stressful situations.
• Treats residents and their families with respect and dignity; ensures confidentiality of resident’s records.
• Interacts professionally with resident/family and provides explanations and verbal reassurance, as necessary.
• Performs all aspects of resident care in an environment that optimizes resident safety and reduces the likelihood of medical/health care errors.
• Supports and maintains a culture of safety and quality.
• Maintains a good working relationship both within the department and with other departments.
• Meets current documentation standards and policies.
• Answers telephone and intercom in a polite and timely manner and communicates information to the appropriate staff or family.
• Manages and operates equipment safely and correctly.
• Checks the computer system to verify that all medical records are current.

Professional Requirements:

• Adheres to dress code, appearance is neat and clean.
• Completes annual education requirements.
• Maintains regulatory requirements.
• Maintains resident confidentiality at all times.
• Reports to work on time and as scheduled, completes work within designated time.
• Wears identification while on duty, uses computerized punch time system correctly.
• Completes inservices and returns in a timely fashion.
• Attends annual review and department inservices, as scheduled.
• Attends all mandatory annual inservices and other trainings as assigned
• Represents the organization in a positive and professional manner.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the facility.

Regulatory Requirements:

• High School graduate or equivalent.
• Ability to work with residents/family and physicians in a friendly and knowledgeable manner.

Language Skills:

• Able to communicate effectively in English, both verbally and in writing.
• Additional languages preferred.

Skills:

• Basic computer knowledge.

Physical Demands:

• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising resident care.