Job Description

POSITION SUMMARY:

Under the direction and supervision of the Director of Nursing/Administrator, maintains resident's medical records in accordance with facility policies and regulations.

ESSENTIAL POSITION FUNCTIONS:

1. Sets up resident's medical records; collects information from nursing staff, physicians, and other sources and updates records; monitors and audits records for completeness and accuracy in accordance with facility policy and regulations and provides information to business office.
2. Processes transfer or discharge records and maintains appropriate records on former residents.
3. Attends orientation and in-service training as required by the state.
4. Understands, complies with, and promotes all rules regarding residents' rights.
5. Promotes positive relationships with residents, visitors and government regulators, to include presenting a professional appearance and attitude.
6. Attends and participates in training, educational activities and staff meetings.
7. Will thin charts as required.
8. Will prepare new charts with all necessary forms for admissions.
9. Will verify that closed charts are in order and stored per policy.
10. 10. Other duties as assigned by the DON and/or the Administrator.

SUMMARY OF QUALIFICATIONS:

1. Must have training and certification or experience as required by the state.
2. Must be able to relate positively to residents and families and to work cooperatively with other employees.
3. Must be capable of maintaining regular attendance.
4. Related administrative experience and/or experience as CNA or Nurse at a level necessary to accomplish the job.
5. Physical and Sensory Requirements (with or without the aide of mechanical devises): Walking, reaching, bending, lifting, grasping, fine hand coordination, pushing and pulling; ability to hear and respond to pages; ability to distinguish smells, tastes and temperatures, ability to read and write; ability to understand and follow written and oral instructions and directions; ability to communicate with residents, families, personnel, vendors and consultants; ability to remain calm under stress.
6. Must meet all local health regulations, and successfully complete a post-offer health assessment.
7. Must be capable of performing the essential functions of this job, with or without reasonable accommodation.

This facility reserves the right to revise the essential position functions and responsibilities as
the need arises.

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