Trainee Rn Clinical Data Abstractor Jobs in Houston, TX

Registered Nurse (RN)

Under the general supervision of the RN Manager, she/he provides intermittent skilled nursing services; communicates the patient's progress with other disciplines and directs, supervises and instructs non-professional home health aide staff in the provision of personal care to the patient.

Qualifications

- Currently licensed in the State of Texas or in accordance with the Board of Nurse Examiners rules for Nurse Licensure Compact (NLC), and

- One year experience as a professional nurse preferred

- Ability to work in a field setting and exhibited ability to make sound nursing judgments

- Ability to assess patient needs and formulate individualized patient care plans to meet those need

- Effective communication skills

- Must have and maintain an automobile to be used for

- Ability to meet physical demand of standing, bending, lifting, stooping or performing other work requiring light physical exertion (up to 30 pounds) on a continuous basis (over 50% of time); or moderate physical exertion (30 to 50 pounds) on a frequent basis (16% to 50% of time); or physical exertion on an occasional basis (up to 15% of time)

Duties

- Under the physician's order, admits patients eligible for home care service

- Assess and evaluates patient needs/problems, identifies mutually agreed upon goals with patients.

- Reports patient status and need for other disciplines to agency RN Clinical Manager and referring physician.

- Develops patient care plan that specifically addresses identified patient problems; nursing problems and goals. Updates care plans on an ongoing basis; revises and resolves patient problems and goals as changes occur and/or

- Admit paperwork and patient care plan submitted to RN Clinical Manager within regulatory time frame

- Assures that all admit paperwork is completed in full for timely data entry of the Plan of care/plan of treatment information.

- Provides intermittent skilled nursing services including assessment, evaluation, procedures, teaching and training activities as outlined in the patient Plan of Treatment.

- Provides skilled nursing visits according to visit schedule and notifies agency of need to alter schedule in any way.

- Reports significant findings to patient's physician and RN Clinical Manager as they

- Submits completed skilled nursing notes, communication notes and home health aide supervisory notes per

- Submits change orders to RN Clinical

- Submits recertification paperwork by the due date provided by the RN Clinical

- Schedules a Clinical case conference with assigned RN Clinical Manager to review patient's needs, problems, level of care and any changes in Plan of care/ plan of treatment for next cert period.

- Completes communication note-documenting plans for recertification were discussed and agreed upon between the physician, patient, and RN Clinical Manager.

- Completes other required documents for recertification: new Medication Profile, updates Care Plan, and updates or completes new Home Health Aide care plan, if applicable.

- Performs HCA supervisory visit at least every 14 days

- Completes Discharge Summary within 5 days of patient discharge or

- Effectively communicates with all members of the healthcare

- Acts as a patient advocate and as such, is a liaison to assist in communicating the patient's needs to the multidisciplinary

- Supervises the home health aide every 14 Provides direction and instruction as it relates to provision of personal care and related support services.

- Completes documentation on Home Health Aide supervisory

- Reports identified performance related problems; patient complaints and/or deviation from the Home Health Aide instruction sheet to the RN Clinical Manager.

- Acts as a preceptor in the orientation of new nursing

- Attends staff meetings and educational in-services per agency

- Continually strives to improve nursing care by broadening knowledge through formal education, attendance at workshops, conferences and participation in professional and related organizations and individual research

- Obtains contact hours as dictated by the State Board of

- Attends at least 50% of the skilled nurse in-services and meetings provided by

- Is responsible for obtaining information provided at skilled nurse in-services and meetings and demonstrates appropriate follow-up related to information given at meetings and in-services.

- As applicable, participates in Performance Improvement program through submission of data collection as it relates to direct patient care problems and serving on Performance Improvement

- Follows agency policies and

- Participates in discharge planning

- Documents Discharge Planning beginning with admit and documents at least 2 weeks in advance instructions given related to discharge.

Completes:

- Patient Care Plan

- Discharge Nurse's Note

- Discharge Summary within 5 days of patient discharge and submit them along with other notes turned in per agency policy.

- Performs other job-related duties as assigned.