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Medical Records Personnel - Skilled Nursing
Career Insights for Registered Nurse (General)
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Scorecard
Based on Maine data
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What they do
A Registered Nurse provides medical care and treatment, educates patients about their conditions, and provides emotional support to patients and families. Works in hospitals, schools, clinics or community health centers. Works under the supervision of a physician or other specialist, and serves as the primary point of care for patients in a hospital setting. May specialize in emergency room work, or treatment for a particular condition, or specialize in working with infants, the elderly or other patient groups. May work as an advanced practice specialists and prescribe medications in addition to offering specialty care.
$89,193 / year median in Maine
-10% projected decline
Job Description
Maintain and keep current the Admittance Log Book.
Assemble and complete all new charts with resident assigned medical records number, name, physical name, or any other information pertinent to the resident.
Maintain resident charts according to Medical Records Procedure Manual to meet regulations and to ensure ease of handling, and reports deficiencies to Director of Nursing / Assistant Director of Nursing.
Establish and maintain a chart alphabetical filing system for both current and discharged residents in the medical records office.
Follow procedures established in Medical Records Procedure Manual for releasing resident information.
Handle discharged residents' charts as outlined in medical Records Procedures Manual; monitor for uncompleted records or notes; notify Director of Nursing, or appropriate department head, of any deficiencies.
Enter all necessary information in the "Death Registry" when a resident expires. Obtain a copy of the death certificate and file with the residents' chart.
Maintain master inventory list at par levels and current costs, updating as needed; monitor par levels with Nursing Unit Usage.
Conduct daily inventory count of all supplies storage areas.
Upon arrival of delivery of supplies, making sure quantities received, match packing slip.
Maintain nursing supplies, place delivered supplies in appropriate storage area, and apply charge tickets.
Review and code as needed all residents charges daily. Forward charges to Business Office.
Keep all supply storage areas neat and orderly.