Performs individualized nursing care for patients/families under the direction of an RN. Assists RNs with the completion of the Resident Assessment Instrument (RAI) and MDS. Records and collects data according to department guidelines. Participates in planning, executing, and contributes to evaluation of patient outcomes. MDS Coordination Coordinates assessment of the resident's physical and psychosocial status, diagnosis and plan of care to ensure appropriateness. Coordinates the resident care plan conferences with the Interdisciplinary Team (IDT) in conjunction with the resident, family, or representative as appropriate. Communicates to the healthcare team the need to revise the plan of care based on the outcome of care conferences and monitors for completion. Coordinates all required Resident Assessment Instruments (RAI) including MDS and RAP summary per state and federal guidelines to ensure timely completion. Monitors IDT sections of the RAI for timely completion, and notifies individual departments to ensure deadlines are met. Demonstrates the knowledge and skills to coordinate care based on the physical, psychosocial, educational, safety and cultural criteria appropriate to the age of the residents served. Notifies manager/director of any barriers to timely, accurate completion and transmission of RAIs/MDS to ensure compliance with deadlines. Assessment Data Collects assessment data per department guidelines of care, including age/cultural specific considerations. Documentation per department/entity guideline of care and policies and procedures. Documents data collected. Communicates/contributes data collected to RN for analysis and interpretation. Department Support Cross covers other department members per request of leadership. Provides information and training to others when needed and as appropriate. Implements plan of care per department guidelines: Refers practices outside of scope to RN. Implements plan of care (IPOC and IPER) using appropriate resources. Updates written plan of care (IPOC) per direction of RN. Collects data indicative of patient/family response to care per department guidelines. Documents patients' response to care. Performs other related duties as assigned. Communication and Coordination Communicates patient and family care needs through documentation. Communicates with other healthcare team members to coordinate patient care activities, workflow, and patient progress. Follows through with identified actions/referrals. Coordinates patient care needs with RN and other staff to ensure continuity. Clinical Competency Vocational Nurse IV Therapy/Blood Withdrawal Certification is required within 6 months of hire or transfer. Certification to be tracked and maintained by the department - REQUIRED Knowledge, Skills, and Abilities Knowledge of Title 22 and OBRA, the RAI/MDS process, Utilization Management criteria and healthcare finances is preferred. Knowledge about care options, clinical goals, anticipated outcomes, regulatory, financial implications and performance improvement. Independent judgment, decision making, self direction and ability to set and achieve priorities. Effective organizational, written and communication skills. Proficient clinical skill and nursing judgment. Ability to successfully meet department's clinical competency requirements.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree