Medical Records Manager jobs in Little Rock, AR

Purpose of Your Job Position

The primary purpose of your job position is to provide direct nursing care to the patients, and to super- vise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in ac- cordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be required by the Director of Nursing Services to ensure that the highest degree of quality care is maintained at all times.

Delegation of Authority

As a Charge Nurse / Shift Supervisor, you are delegated the authority, responsibility, and account- ability necessary for carrying out your assigned duties.

Job Functions

Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work

is similar, related, or is an essential function of the position.

Duties and Responsibilities

Administrative Functions

• Direct the day-to-day functions of the nursing assistants in accordance with current rules, regula- tions, and guidelines that govern the long-term care facility.
• Ensure that all nursing personnel assigned to you comply with the written policies and procedures established by this facility, it’s corporate office, and governing
• Meet with your assigned nursing staff, as well as support personnel, in planning the shifts’ services, programs, and activities.
• Ensure that the Nursing Service Procedures Manual is current and reflects the day-to-day nursing procedures performed in this
• Ensure that all nursing service personnel comply with the procedures set forth in the Nursing Ser- vice Procedures Manual.
• Make written and oral reports/recommendations concerning the activities of your shift as
• Cooperate with other patient services when coordinating nursing services to ensure that the pa- tient’s total regimen of care is maintained.
• Participate in the development, maintenance, and implementation of the facility’s quality assurance program for the nursing service department.
• Participate in facility surveys (inspections) made by authorized government agencies as may be re-
• Periodically review the patient’s written discharge plan. Participate in the updating of the patient’s written discharge plan as required.
• Interpret the department’s policies and procedures to personnel, patients, visitors, and government agencies as required.
• Admit, transfer, and discharge patients as
• Complete accident/incident reports as
• Write patient charge slips and forward to the Business
• Maintain the Daily Census Report and submit to the Business Office as
• Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as

Charting and Documentation Functions

• Complete and file required recordkeeping forms/charts upon the patient’s admission, transfer, and/ or
• Ensure that attending physicians review treatment plans, record and sign their orders, progress notes, , in accordance with established policies.
• Receive telephone orders from physicians and record on the Physicians’ Order
• Transcribe physician’s orders to patient charts, cardex, medication cards, treatment/care plans, as
• Chart nurses’ notes in an informative and descriptive manner that reflects the care provided to the patient, as well as the patient’s response to the care.
• Fill out and complete accident/incident Submit to Director as required.
• Chart all reports of accidents/incidents involving Follow established procedures.
• Record new/changed diet Forward information to the Dietary Department.
• Report all discrepancies noted concerning physician’s orders, diet change, charting error, etc., to the Nurse Supervisor.
• Fill out and complete transfer forms in accordance with established
• Ensure that appropriate documentation concerning unauthorized discharges is entered in the pa- tient’s medical record in accordance with established
• Perform routine charting duties as required and in accordance with established charting and docu- mentation policies and procedures.
• Sign and date all entries made in the patient’s medical

Drug Administration Functions

• Prepare and administer medications as ordered by the
• Verify the identity of the patient before administering the medication/treatment.
• Ensure that prescribed medication for one patient is not administered to
• Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the Report needs to the Director of Nursing Services.
• Order prescribed medications, supplies, and equipment as necessary, and in accordance with estab- lished
• Ensure that narcotic records are accurate for your shift, and notify the Director of Nursing Services of all drug and narcotic
• Review medication cards for completeness of information, accuracy in the transcription of the physi- cian’s order, and adherence to stop order policies.
• Notify the attending physician of automatic stop orders prior to the last dosage being
• Dispose of drugs and narcotics as required, and in accordance with established

Personnel Functions

• Participate in employee performance evaluations as asked, determining your shift’s staffing require- ments, and making recommendations concerning employee dismissals, transfers,
• Inform the Director of Nursing Services of staffing needs when assigned personnel fail to report to
• Report absentee call-ins to the Nurse
• Develop work assignments and/or assist in completing and performing such
• Provide leadership to nursing personnel assigned to your unit/shift.
• Meet with your shift’s nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services.
• Ensure that department personnel, patients, and visitors follow the department’s established poli- cies and procedures at all times.
• Develop and maintain a good working rapport with inter-departmental personnel, as well as other departments within the facility to ensure that nursing services and activities can be adequately maintained to meet the needs of the patients.
• Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and
• Review complaints and grievances made or filed by your assigned
• Make appropriate reports to the Director of Nursing Services as required or as may be
• Follow facility’s established
• Ensure that departmental disciplinary action is administered fairly and without regard to race, color, creed, national origin, age, sex, religion, handicap, or marital

• Receive/give the nursing report upon reporting in and ending shift duty
• Report occupational exposures to blood, body fluids, infectious materials, and hazardous chemicals in accordance with the facility’s policies and procedures governing accidents and

Nursing Care Functions

• Inform nursing personnel of new admissions, their expected time of arrival, room assignment,
• Ensure that rooms are ready for new
• Greet newly admitted patients upon Escort them to their rooms as necessary.
• Participate in the orientation of new patients/family members to the
• Make rounds with physicians as
• Requisition and arrange for diagnostic and therapeutic services, as ordered by the physician, and in accordance with our established
• Consult with the patient’s physician in providing the patient’s care, treatment, rehabilitation, etc., as
• Review the patient’s chart for specific treatments, medication orders, diets, , as necessary.
• Make periodic checks to ensure that prescribed treatments are being properly administered by certi- fied nursing assistants and to evaluate the patient’s physical and emotional
• Notify the patient’s attending physician and next-of-kin when the patient is involved in an accident or incident, when there is a change in the patient’s condition, and in the event of
• Carry out restorative and rehabilitative programs, to include self-help and
• Inspect the nursing service treatment areas daily to ensure that they are maintained in a clean and safe manner.
• Administer professional services such as; catheterization, tube feedings, suction, applying and changing dressings/bandages, packs, colostomy, and drainage bags, taking blood, giving massages and range of motion exercises, care for the dead/dying, , as required.
• Use doctor-prescribed restraints when necessary and in accordance with established policies and
• Obtain sputum, urine and other specimens for lab tests as
• Take and record TPRs, blood pressures, , as necessary.
• Monitor seriously ill patients as
• Check foods brought into the facility by the patient’s family/visitors to ensure that it is within the pa- tient’s dietary allowances. Report problem areas to the Director of Nursing Services and Dietary Su-
• Ensure that patients who are unable to call for help are checked
• Meet with patients, and/or family members, as necessary. Report problem areas to the Director of Nursing
• Assist in arranging transportation for discharged patients as
• Call funeral homes when requested by the family. Ensure that established post-mortem procedures are

Staff Development Functions

• Participate in developing, planning, conducting, and scheduling in-service training classes that pro- vide instructions on “how to do the job,” and ensure a well-educated nursing service
• Maintain an effective orientation program that orients the new employee to your shift, its policies and procedures, and to his/her job position and duties.
• Attend and participate in annual OSHA and CDC in-service training programs for hazard communica- tion, TB management, and blood borne pathogens standard, advance directive in-service training programs for the staff and community, and any and ALL other in-service
• Attend and participate in continuing education and training programs designed to keep you abreast of changes in your profession, as well as to maintain your license on a current

Safety and Sanitation Functions

• Monitor your assigned personnel to ensure that they are following established safety regulations in the use of equipment and supplies, and ALL departmental and facility policies and
• Ensure that all personnel performing tasks that involve potential exposure to blood/body fluids par- ticipate in appropriate in-service training programs prior to performing such tasks, and that an ade- quate supply of personal protective equipment are on hand and are readily available to personnel who perform such procedures.

• Monitor departmental personnel for adherence to all safety and infection control policies and proce-

Equipment and Supply Functions

• Recommend to the Director of Nursing Services the equipment and supply needs of your unit/shift.
• Ensure that only trained and authorized personnel operate your unit/shift’s equipment, and that they do so in a safe manner.
• Monitor nursing procedures to ensure that nursing service supplies are used in an efficient manner to avoid
• Ensure that appropriate MSDSs are on file for hazardous chemicals used in the nursing service de-

Care Plan and Assessment Functions

• Review care plans daily to ensure that appropriate care is being
• Inform the Director of Nursing Services of any changes that need to be made on the care
• Ensure that your nurses’ notes reflect that the care plan is being followed when administering nurs- ing care or
• Ensure that your assigned CNAs are aware of the patient care plans. Ensure that the CNAs refer to the patient’s care plan prior to administering daily care to the patient.
• Assist the Patient Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and

Patient Rights’ Functions

• Maintain the confidentiality of all patient care
• Ensure that all patients are treated fairly, and with kindness, dignity, and
• Ensure that all nursing care is provided in privacy, and that personnel are aware of and uphold pa- tients’
• Knock before entering the patient’s room, and adhere to all facility patient rights and privacy poli- cies and procedures.
• Review all grievances and complaints made by the patients and report to the Director of Nursing
• Report and investigate all allegations of patient abuse and/or misappropriation of patient
• Ensure that patients’ refusal of treatment requests are

Miscellaneous Functions

• Provide data to the Quality Assurance & Assessment Committee as

Working Conditions

• Works in office area(s) as well as throughout the nursing service area (i.e., drug rooms, nurses’ sta- tions, patient rooms, ), moving intermittently during working hours.
• Is subject to frequent interruptions by patients, personnel, visitors, government agencies/personnel, , under all conditions and circumstances.
• Is subject to hostile and emotionally upset patients, family members, personnel, and
• Communicates with nursing personnel and other department
• Works beyond normal working hours, on weekends and holidays, in other positions, and in call-back situations (e.g., severe weather, evacuation, post-disaster, ), when necessary.
• Attends and participates in continuing educational
• Is subject to injury from falls, burns from equipment, odors, etc., throughout the work day, as well as to reactions from dust, disinfectants, tobacco smoke, and other air
• Is subject to exposure to infectious waste, diseases, conditions, , including TB, Covid variants, AIDS, Hepatitis B viruses, and may be subject to the handling of and exposure to hazardous chemicals
• Maintains a liaison with the patients, their families, support departments, etc., to adequately plan for the patients’ needs.

Education

• Must possess, as a minimum, a Nursing Degree from an accredited college or university, or be a graduate of an approved LPN/LVN

• On-the-job training provided.

Experience

Specific Requirements

• Must possess a current, unencumbered, active Arkansas RN or LPN license to
• Must be able to read, write, speak, and understand the English
• Must possess the ability to make independent decisions when circumstances warrant such
• Must possess the ability to deal patiently, tactfully, with a cheerful disposition and enthusiasm with personnel, patients, family members, visitors, government agencies/personnel, and the general pub- lic based on whatever maturity level they are currently
• Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to long-term
• Must possess leadership and supervisory ability and the willingness to work harmoniously with and supervise other personnel.
• Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, , that are necessary for providing quality care.
• Must be able to relate information concerning a patient’s
• Must not pose a direct threat to the health or safety of other individuals in the
• Must be willing to follow all company, state and regulatory policies related to Infection Control and Vaccination requirements.

Physical and Sensory Requirements

(With or Without the Aid of Mechanical Devices)

• Must be able to move intermittently throughout the work
• Must be able to speak and write the English language in an understandable
• Must be able to cope with the mental and emotional stress of the position due to relating to and working with the ill, disabled, elderly, emotionally upset, and, at times, hostile
• Must be able to see and hear or use prosthetics that will enable these senses to function adequately to ensure that the requirements of this position can be fully met.
• Must function independently and have flexibility, personal integrity, and the ability to work effectively with patients, personnel, and support agencies.
• Must meet the general health requirements set forth by the policies of this
• Must be able to push, pull, move, and/or lift a reasonable minimum of pounds to a reasonable height and be able to push, pull, move, and/or carry such weight a reasonable
• May be necessary to assist in the evacuation of patients during emergency

Job Position Analysis Information

YES Tasks assigned to this position do involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals

YES Functions Require Repetitive Motion

YES Weight Lifting requirements do apply.

YES Functions Require Prolonged Sitting, Standing, and/or Bending