Commission Rn Chart Auditor Jobs in Charleston, SC

The Reserve Health and Rehab

Job Description: Registered Nurse

Reports to: Director of Nursing Services

Department:  Nursing Classification:  Hourly (non-exempt)

Our expectation is that you will perform your job in a manner consistent with our Core Values CELEBRATION – ACCOUNTABILITY - PASSION FOR LEARNING - LOVE ONE ANOTHER - INTELLIGENT RISK TAKING - CUSTOMER SECOND - OWNERSHIP

POSITION SUMMARY:  The primary purpose of your job position is to provide primary care to specific residents under the medical direction and supervision of the residents’ attending physicians or the Medical Director of the facility, with an emphasis on assessment, illness prevention and health care management.  You will also assist in modifying the treatment regimen to meet the physical and psychosocial needs of the resident, in accordance with established medical practices and the requirements of this state and the policies and goals of this facility.

ESSENTIAL DUTIES AND RESPONSIBILITIES: Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position.

• Confer with the Medical Director and the attending physician regarding specific residents assigned to you.

• Consult with the physician concerning resident evaluation and assist the Director of Nursing Services in planning and developing the nursing services to be performed for the resident.

• Initiate requests for consultation or referral.  Respond to requests from the resident, physician, or nursing staff.

• Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems.

• Determine when to refer the resident to a physician for evaluation, supervision, or directions.

• Perform administrative duties regarding assigned residents, such as completing medical forms, reports, evaluations, studies, charting, etc.

• Implement and maintain established policies, procedures, objectives, quality assurance, safety and environmental and infection control.  Interpret these to the physician, resident, family members, and public, as appropriate.

• Make written and oral reports/recommendations to the attending physician, Medical Director, or the Administrator concerning the status and care of the assigned resident.

• Participate in the planning and evaluation of the written policies and procedure that govern the day-to-day functions of the nursing service department.

• Participate in facility surveys (inspections) made by authorized government agencies.

• Resolves complaints and grievances made by nursing department personnel.

• Ensures that nursing department employment actions are administered fairly and in compliance with the facility’s Policy Against Discrimination, Harassment and Retaliation.

• Supervises and assists in management of the infection control program including ensuring that personal protective equipment is used in the handling of infectious materials by nursing personnel.

• Assists in the development of preliminary and comprehensive assessments of the nursing needs of each resident are performed in furtherance of the resident care planning policy.

• Administer services within the applicable scope of nursing practice, which may include: catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, etc., as appropriate and in accordance with applicable standards.

• Prepare and administer medications as ordered by the physician.

• Review medication cards for completeness of information, accuracy in the transcription of the physician’s order, and adherence to stop order policies.

• Dispose of drugs and narcotics as required, and in accordance with established procedures.

• Chart nurses’ notes in professional and appropriate manner that timely, accurately and thoroughly reflects the care provided to the resident, as well as the resident’s response to the care.

• Chart all reports of accidents/incidents involving residents.

• Chart all changes in resident condition and the response to those changes.

• Chart all communications with the resident’s attending physician regarding the resident, the resident’s treatment, or the response to that treatment. 

• Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures and applicable state and federal regulations.

• Verify that nurses’ notes reflect that the care plan is being followed when administering nursing care or treatment.

• Ensure that assigned certified nursing assistants (CNAs) are aware of the resident care plan. 

• Ensure that the CNAs refer to the resident’s care plan prior to administering daily care to the resident. 

• Ensures that adequate stock levels of medications, medical supplies and equipment are maintained.

• Assist the Quality Assessment and Assurance Committee in developing and implementing appropriate plans of action to correct identified deficiencies.

• Performs other duties as may be assigned.

QUALIFICATIONS:

Education and/or Experience: 

• High School Diploma or equivalent

• Graduate of an accredited Registered Nurse program.

Certificates and Licenses:

• Must possess an active license to practice as a Registered Nurse valid in this state.

Other Specific Requirements

• Must provide evidence of being free of tuberculosis infection upon hire and as set forth by the policies of the facility.

• Must be able to read, write, speak and understand the English language.

• Must possess the ability to make independent decision when circumstances warrant such action.

• Must possess the ability to deal tactfully with personnel, residents, family members, visitors, government agencies/personnel, and the general public.

• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term care.

• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.

• Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents.

WORK ENVIRONMENT:

• Works throughout the nursing service area (i.e. nurse’s stations, resident rooms, etc.).

• Moves intermittently during working hours.

• Is subject to frequent interruptions.

• Interacts with residents, personnel, visitors, government agencies/personnel, etc., under all conditions and circumstances.

• Is subject to hostile and emotionally upset residents, family members, personnel, and visitors.

• Communicates with the medical staff, nursing personnel, and other department supervisors.

• Works beyond normal working hours and on weekends and holidays when necessary.  May be on call 24 hours per day, 7 days per week.

• Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.).

• Is subject to injury from falls, burns from equipment, odors, etc., as well as to reactions from dust, disinfectants, tobacco smoke, and other air contaminants.

• Is subject to exposure to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses.

• May be subject to the handling of and exposure to hazardous chemicals.

PHYSICAL AND SENSORY REQUIREMENTS (with or without the aid of mechanical devices):

• Must be able to move intermittently throughout the work day.

• Must be able to cope with the mental emotional and stress of the position.

• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.

• Must function independently, have flexibility, personal integrity, and the ability to work effectively.

• Must meet the general health requirements set forth by the policies of this facility which may include a medical and physical examination.

• Must be able to relate to and work with ill, disabled, elderly, emotionally upset, and, at times, hostile people within the facility.

• Must be able to lift up to 25 pounds.  Requires infrequent lifting of more weight up to 50 pounds.  Occasional pushing and pulling of carts.

• May be necessary to assist in the evacuation of residents during emergency situations.