Medical Records - LVN

Caraday Healthcare•San Angelo, TX

About The Position

Under the supervision of the Director of Nursing, the Medical Records-LVN performs clinical administrative duties associated with patient care unit operations. The role also provides nursing care to residents as prescribed by the physician, in accordance with nursing practice standards and regulations, and as directed by the Director of Nursing. Responsibilities include maintaining and processing patient records, transcribing and implementing physician orders, supporting infection control, and helping ensure resident safety and quality nursing care.

Requirements

Current LVN license.
CPR certification is required; 30 days are provided to complete a course and become certified.
Ability to understand, remember, and carry out verbal or written instructions in English.
Ability to complete assignments in a timely manner.
Ability to remain flexible and positive amid intermittent interruptions.

Nice To Haves

Two years of nursing experience in long-term care or skilled nursing.

Responsibilities

Communicate in writing and verbally with healthcare team members, patients, and visitors, including by telephone.
Maintain the confidentiality of patient information.
Assemble, complete, and process patient charts.
Ensure patient records are accurately identified and maintain clinical records according to facility policy.
Accurately and promptly transcribe doctors’ orders and implement physicians’ orders.
Review charts daily for incomplete histories and operative summaries and bring compliance issues to the appropriate healthcare team member for correction.
Obtain closed records from Medical Records as needed.
Initiate required nursing forms for new admissions.
Order unit supplies and assist with receiving, distributing, and sorting supplies brought to the unit.
Enter, transcribe, and confirm doctor and hospital admission orders for new admissions to the community.
Support and enforce infection-control policies and procedures.
Follow established standards, policies, and procedures when providing nursing care.
Accept accountability for clinical care of assigned patients, including supervision of nonprofessional personnel.
Support nursing-care standards by adhering to existing policies and procedures.
Seek guidance when encountering nursing procedures or responsibilities that have not been mastered.
Promote positive public relations with patients, residents, family members, and guests.
Use tactful and appropriate communication in sensitive and emotional situations.
Follow appropriate workplace behavior and the dress code.
Adhere to Residents’ Rights guidelines and ensure resident safety.