Medical Records Nurse

To manage the medical records on each resident in accordance with established facility protocol, standards of practice and state and federal regulations and to ensure that these records are complete, accurately documented, readily accessible and systematically organized.

Accountability: Director of Nursing

DUTIES AND RESPONSIBILITIES:

1. Assemble admission records.
2. Preform regular audits to verify completeness, accuracy and internal consistency of each record.
3. Audit discharge charts for accuracy and completeness; file in the appropriate order.
4. Perform coding and maintain a diagnosis list on each medical record.
5. Participate in Case Mix audits providing assistance as needed.
6. Maintain an inventory of all forms used in medical records.
7. Answer the telephone courteously and relay messages.
8. Perform or assist with monthly reviews of incident/accident reports for nursing.
9. Provide administrative support, as requested.
10. Understand and follow fire, safety, sanitation, Blood-borne Pathogen rules and Hazard
11. Communication programs.
12. Promote a positive relationship with residents, visitors, and government regulators to include a professional attitude and appearance.
13. Prevent abuse, neglect and exploitation in the elderly.
14. Promote a safe, clean environment in which the residents may live.
15. Any other duties and responsibilities, as requested by the Administrator.
16. Become a participating facility team member with the residents as first priority.
17. Attend facility meetings.

PHYSICAL REQUIREMENTS:

• Hold/handle
• Lift
• Carry
• Reach – at and below shoulder height
• Push/pull
• Grasp and handle – pens, paperwork and small equipment
• Sit, stand and walk
• Twist, bend, stoop, kneel, and squat
• Fine hand motor coordination
• Ability to read and write legibly
• Ability to comprehend and follow instructions

COGNITIVE AND SENSORY REQUIREMENTS:

Talking: Communicating with residents, families, visitors and staff

Hearing: To communicate effectively on the telephone, Taking instructions from the Administrator, To respond appropriately to disaster instructions and pages

Sight: For performing job effectively and correctly

Smell: For accurate detection and maintenance of facility odors

LICENSURE REQUIREMENTS:

Must be a Licensed Practical Nurse (L.P.N.) currently licensed and in good standing with the Board of Nursing in the State in which the facility is located.

SUMMARY OF OCCUPATIONAL EXPOSURE:

Tasks and procedures performed by the employee involve risks classified by C.D.C. as

Category III. (No contact with blood or other bodily fluids to which universal precautions apply, if regular duties are performed.)

OTHER CONSIDERATIONS AND REQUIREMENTS:

Must be able to tolerate a high pace as typical for a nursing facility. Must be able to take and give instructions well and enjoy working with the elderly. Although employee is required to sit for prolonged periods of time, he/she must also be able to tolerate prolonged standing and walking.