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 physicians and in accordance with nursing practice standards, regulations, and direction from the Director of Nursing. The position maintains and processes patient records, transcribes and implements physician orders, and supports admissions and unit operations. It also requires adherence to infection-control policies, nursing standards, facility procedures, and residents’ rights while promoting resident safety and positive communication with patients, families, visitors, and the healthcare team.

Requirements

Current LVN license.
CPR certification required; 30 days will be given to complete a course and obtain certification.
Ability to understand, remember, and carry out verbal or written instructions in English.
Ability to complete assignments in a timely manner.
Ability to be flexible and positive with 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 as indicated.
Ensure patient records are accurately identified and maintain accurate clinical records in accordance with facility policy.
Transcribe doctors’ orders accurately and promptly implement physicians’ orders in accordance with facility policy.
Review charts daily for incomplete histories and operative summaries and bring compliance issues to the appropriate healthcare team member’s attention for correction.
Obtain closed records from Medical Records as needed.
Initiate required nursing forms for new admissions.
Order unit supplies, maintain inventory, 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 the 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.
Use appropriate workplace behavior and adhere to the dress code.
Understand and adhere to Residents’ Rights guidelines and assure resident safety.