Wound / Medical Records Nurse
- Employer
- Miller's Health Systems
- Location
- Sullivan County, IN
- Closing date
- Jun 15, 2021
View more
- Profession
- Nurse
- Specialty
- Medical Management
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Job Description
WHO YOU ARE
Are you a Registered Nurse or Licensed Practical Nurse with excellent clinical skills? Are you a confident as a healthcare professional and value the opportunity to develop relationships with your co-workers and the patients under your care? Are you looking for a job offering opportunities for growth and variety? Do you want a job thats more than just a job its also a future?
THIS POSITION WILL BE RESPONSIBLE FOR MEDICAL RECORDS PROCESSES INCLUDING:
* Organizing admission chart
* Auditing charts for completion
* Adding diagnoses codes to PCC
* Updating MD progress notes
* Checking UDA reports
* Keeping order review dates accurate for each month
* Running all medical records requests
* Keeping current and organized medical records charts in MR room
THIS POSITION WILL ALSO BE RESPONSIBLE FOR WOUND NURSE DUTIES:
1. Conduct weekly skin rounds to assess, measure and treat all pressure ulcers and wounds as outlined in the "Wound and Non-wound Assessment and Documentation" policy.
2. Assist the wound physician on weekly skin rounds if applicable. Also communicate any new areas to the wound physician on wound rounds.
3. Document according to NPUAP standards of practice on the weekly wound assessmentwithin the Point Click Care EMR.
4. If able, compile the wound report from Point Click Care and submit to the Administrator, Director of Nurses, Dietary Manager, RD, Regional VP, QA Nurse, and VP of Quality Assurance via email following wound rounds each week.
5. Communicate wound deterioration and suggest alternative treatment options to physician.
6. Communicate wound status at least twice monthly to family or responsible party.
7. Notify physician and family/responsible party of all healed wounds.
8. Review and modify health care plan weekly to ensure care plan goals and interventions are appropriate.
9. Attend the weekly Wound, Weight, and Hydration meeting and be prepared to lead all wound discussions with the interdisciplinary health care plan team. Assist with meeting documentation as assigned.
10. Implement pressure reduction devices as necessary to prevent and promote healing ofwounds.
11. Monitor staff compliance with turning, repositioning, off loading of heels and prevention of pressure ulcer development.
12. Provide or assist with skin care and pressure ulcer prevention and treatment in- servicing.
13. Other tasks as assigned by the Administrator or Director of Nursing.
PART OF THE DUTIES FOR THIS POSITION WILL ALSO BE NURSING SUPPLY
WHO YOU ARE
Are you a Registered Nurse or Licensed Practical Nurse with excellent clinical skills? Are you a confident as a healthcare professional and value the opportunity to develop relationships with your co-workers and the patients under your care? Are you looking for a job offering opportunities for growth and variety? Do you want a job thats more than just a job its also a future?
THIS POSITION WILL BE RESPONSIBLE FOR MEDICAL RECORDS PROCESSES INCLUDING:
* Organizing admission chart
* Auditing charts for completion
* Adding diagnoses codes to PCC
* Updating MD progress notes
* Checking UDA reports
* Keeping order review dates accurate for each month
* Running all medical records requests
* Keeping current and organized medical records charts in MR room
THIS POSITION WILL ALSO BE RESPONSIBLE FOR WOUND NURSE DUTIES:
1. Conduct weekly skin rounds to assess, measure and treat all pressure ulcers and wounds as outlined in the "Wound and Non-wound Assessment and Documentation" policy.
2. Assist the wound physician on weekly skin rounds if applicable. Also communicate any new areas to the wound physician on wound rounds.
3. Document according to NPUAP standards of practice on the weekly wound assessmentwithin the Point Click Care EMR.
4. If able, compile the wound report from Point Click Care and submit to the Administrator, Director of Nurses, Dietary Manager, RD, Regional VP, QA Nurse, and VP of Quality Assurance via email following wound rounds each week.
5. Communicate wound deterioration and suggest alternative treatment options to physician.
6. Communicate wound status at least twice monthly to family or responsible party.
7. Notify physician and family/responsible party of all healed wounds.
8. Review and modify health care plan weekly to ensure care plan goals and interventions are appropriate.
9. Attend the weekly Wound, Weight, and Hydration meeting and be prepared to lead all wound discussions with the interdisciplinary health care plan team. Assist with meeting documentation as assigned.
10. Implement pressure reduction devices as necessary to prevent and promote healing ofwounds.
11. Monitor staff compliance with turning, repositioning, off loading of heels and prevention of pressure ulcer development.
12. Provide or assist with skin care and pressure ulcer prevention and treatment in- servicing.
13. Other tasks as assigned by the Administrator or Director of Nursing.
PART OF THE DUTIES FOR THIS POSITION WILL ALSO BE NURSING SUPPLY
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