Rn Chart Review Jobs in Indiana (NOW HIRING)

Job Summary 
The Registered Nurse (RN) provides patient-centered care through the nursing process of assessment, diagnosis, planning, implementation, and evaluation. This role is responsible for coordinating and delivering high-quality care based on established clinical protocols and physician/provider orders. The RN collaborates with physicians, nurses, and other healthcare professionals to ensure effective patient care and desired outcomes, while maintaining a supportive and compassionate environment for patients and their families. 
Essential Functions

• Coordinates and delivers high-quality, patient-centered care in accordance with organizational policies, protocols, and the nursing process.
• Conducts thorough patient assessments and documents findings accurately, reporting changes in condition to the appropriate care team members.
• Utilizes knowledge of human growth and development to provide age-appropriate care and education.
• Administers prescribed medications, monitors for side effects, and documents administration in accordance with standards of practice.
• Assists physicians during procedures within the scope of documented competency and skill level.
• Collaborates with the healthcare team to develop, implement, and evaluate individualized care plans based on patient assessments and needs.
• Responds to medical emergencies and participates in life-saving interventions, such as CPR and code team activities, as appropriate.
• Advocates for the rights and needs of patients, ensuring their voices are heard and respected in care planning and delivery.
• Provides patient and family education on medical conditions, treatment plans, and post-discharge care, ensuring understanding and adherence to instructions.
• Implements and adheres to infection control protocols to prevent the spread of healthcare-associated infections.
• Monitors and operates medical equipment (e.g., IV pumps, monitors, ventilators) as needed for patient care and safety.
• Promotes patient safety by adhering to National Patient Safety Goals and maintaining a clean, safe environment for patients and staff.
• Participates in audits, chart reviews, and compliance checks to ensure adherence to standards of practice and regulatory requirements.
• Demonstrates responsible decision-making in planning, delegating, and providing care based on patient needs and organizational policies.
• Documents patient care and education thoroughly and promptly in the medical record.
• Engages in professional development to maintain clinical competency and understanding of current nursing standards and regulations.
• Participates in performance improvement initiatives, including data collection and process development, to enhance patient outcomes and care delivery.

Telemetry RN:

• Using telemetry equipment to track heart rhythms (EKG), blood pressure, oxygen saturation, and other vital signs.
• Analyzes telemetry data to identify trends, abnormalities, and potential problems, and reports these findings to physicians.
• Provides direct patient care, including medication administration, wound care, and patient education, with a focus on cardiac health.
• Recognizes and responds to emergencies, such as cardiac arrest, and implements appropriate interventions.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• 0-2 years of experience in a clinical nursing role or student clinical rotations in an acute care setting required

Knowledge, Skills and Abilities

• Strong knowledge of the nursing process and clinical nursing practices.
• Ability to perform thorough patient assessments and communicate findings effectively.
• Proficient in administering medications and monitoring for side effects.
• Effective communication and interpersonal skills to collaborate with interdisciplinary teams.
• Strong organizational skills and attention to detail in documenting patient care.
• Knowledge of safety standards, infection control, and quality improvement initiatives.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required
• BCLS - Basic Life Support required
• ACLS - Advanced Cardiac Life Support preferred
• PALS - Pediatric Advanced Life Support preferred
• NRP - Neonatal Resuscitation preferred
• Refer to facility or unit-specific guidelines for additional requirements.