Registered Nurse (RN) & Medical Records Clerk (Rancho Cucamonga)

compensation: DOE
employment type: full-time

The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Essential Job Functions/Responsibilities

1. Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness(es).

2. Regularly re-evaluates patient nursing needs.

3. Initiates the plan of care and makes necessary revisions as patient status and needs change.

4. Uses health assessment data to determine nursing diagnosis.

5. Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.

6. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.

7. Counsels the patient and family in meeting nursing and related needs.

8. Provides health care instructions to the patient as appropriate per assessment and plan of care.

9. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.

10. Acts as Case Manager when assigned by Clinical Supervisor/Nursing Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Position Qualifications

1. Registered nurse with current licensure to practice professional nursing in the state.

2.Graduate of National League for the Nursing accredited school of nursing.

3.Maintains a current CPR certification.

4.Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order.

5. Public health or home care nursing is preferred.

6.Self-directed and able to work with minimal supervision.

7.Demonstrates excellent observation, problem-solving, verbal and written communication skills; nursing skills per competency checklist.

8. Shows the ability to organize and prioritize workload independently.

9.Management experience not required. Responsible for supervising home health aides.

10.Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills.
Job Description Summary- Medical Records Clerk

Assists the Clinical Records Manager in maintaining and protecting the organization’s clinical records in order.

Essential Job Functions/Responsibilities

1. Manages all daily clinical records functions.

2. Ensures clinical record systems are maintained in compliance with state, federal and Joint Commission regulations.

3. Protects all clinical records through the establishment and implementation of control procedures for all open and closed records.

4. Protects the confidentiality of patient and organization information through effective controls and supervision of clinical records manager.

5. Forwards copies of clinical records to authorized users according to policy.

6. Helps monitor aged unsigned physician orders and submits second and third requests for signed orders to overdue physicians through the supervision of the Clinical Records Manager.

7. Supervises the use of the clinical records information system and maintains a comprehensive working knowledge of the system including upgrades and enhancements.

8. Assists the members of the clinical record team to ensure accurate and prompt filing and retrieval of clinical records.

The above statements are intended to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.

Position Qualifications

1. Some experience in clinical records management, with one year or more preferred.

2. Demonstrates good communication and public relations skills.

3. Demonstrates autonomy, organization, assertiveness, flexibility, and cooperation in performing job responsibilities.
  • Principals only. Recruiters, please don't contact this job poster.
  • do NOT contact us with unsolicited services or offers

post id: 7003436674


best of [?]