Centered in the heart of Yuba-Sutter County, Adventist Health and Rideout has been one of the area's leading healthcare providers since 1907. We are comprised of a 221-bed hospital, 21 physician clinics, home care services, comprehensive cancer care and a vast scope of award-winning services located throughout Marysville and the surrounding areas. The allure of Marysville's community is complimented by its proximity to major metropolitan cities in the Bay Area and Sacramento, as well as just a quick drive to Lake Tahoe.
Job Summary:
Assists the Nurse Supervisor/Charge Nurse in day-to-day recording and charting of medical or administrative information in accordance with current federal, state, and local standards, guidelines, and regulations that govern medical records, and as may be required by the Director of Nursing Services, to ensure that our medical records are maintained in an informative and descriptive manner.
Job Requirements:
Education and Work Experience:
- High School Education/GED or equivalent: Preferred
- Associate’s/Technical Degree or equivalent combination of education/related experience: Preferred
- One year's relevant experience: Preferred
- Skilled nursing facility experience: Preferred
Licenses/Certifications:
- Basic Life Support (BLS OR HS-BLS OR RQIBLS) American Heart Association: Preferred
Essential Functions:
- Records medical and administrative information in accordance with our established charting and documentation policies and procedures. Maintains the Daily Census Report and submits to Nurse Supervisor/Charge Nurse. Maintains an up-to-date roster of residents for your assigned unit. Fills out resident charge slips and submit to the Business Office.
- Transcribes physicians’ orders to care plans, medication cards, treatment plans, etc., as required. Reports to the Nurse Supervisor/Charge Nurse discrepancies found in transcribing physicians’ orders, diet orders/changes and charting. Reviews medication cards for completeness of information, accuracy in the transcription of the physician’s order and legibility, as directed. Charts nurses’ notes in an informative and descriptive manner that reflects the care provided as well as the resident’s response to the care.
- Admits, transfers and discharges residents. Assists in arranging for transportation, packing residents’ belongings, escorting them to discharge/transfer area and loading, as necessary. Completes necessary medical and administrative records upon the resident’s admission, transfer, and/or discharge.
- Informs nursing service personnel of new admissions, their expected time of arrival and room assignment. Greets newly admitted residents upon admission. Escorts to room as necessary. Assists in escorting residents’ to/from activity and social functions. Encourages attending physicians to record and sign progress notes and physicians’ orders on a timely basis and in accordance with current regulations. Assists in recordkeeping functions for nurse aide trainees. Reports administrative problem areas to the Director. Assists in developing and implementing corrective action.
- Ensures that all personnel involved in providing care to the resident are aware of the resident’s care plan and that nursing personnel refer to the resident’s care plan prior to administering daily care to the resident. Transcribes data to the care plan as necessary. Assists in scheduling assessment and care plan meetings as directed.
- Performs other job-related duties as assigned.
Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
