Registered Nurse (RN) Job Description
Complete and file required recordkeeping forms/charts upon the residents admission, transfer, and/or discharge
Receive telephone orders from physicians and record on the physician order sheet.
Transcribe physicians orders to resident charts, medication sheets, treatment/care plans, as required.
Chart nurses notes in an informative and descriptive manner that reflects the care provided to the resident following facility standards for charting.
Report all discrepancies noted concerning physicians’ orders, diet change, charting error, etc.
Perform routine charting duties as required and in accordance with nursing standards, and established facility charting and documentation policies and procedures.
Sign and date all entries made in the residents’ medical record.
Direct the day to day functions of the nursing staff in accordance with current rules, regulations, and guidelines that govern the long-term care facility.
Ensure that all nursing personnel assigned to you comply with the written standards, policies and procedures established by this facility.
Make written and oral reports/recommendations concerning the activities of your unit as required.
Participate in employee performance evaluations.
Ensure that all nursing service personnel are in compliance with their respective job descriptions.
Participate in facility surveys (inspections) made by authorized government agencies as may be requested.
Admit, transfer and discharge residents as required.
Complete accident/incident reports as necessary.
Perform administrative duties such as completing medical forms, reports, evaluations, studies, charting etc. as necessary.