Medical Records Nurse
3 weeks ago
Under the general supervision of the Nursing Manager, the Registered Nurse assesses, plans, implements and evaluates Resident care, within the context of the Park Place Philosophy of Care. Working in a collaborative relationship with all members of the interdisciplinary team, the Registered Nurse ensures the delivery of Resident/ family centred care by demonstrating and/or providing clinical leadership, guidance on clinical or health-related care issues and by assisting individual clients and their families to respond to changing health care needs. The Registered Nurse demonstrates competent gerontological nursing practice in accordance with Professional Standards and established Park Place policies, procedures, and clinical guidelines. The Registered Nurse will ensure a commitment to safe quality Resident care as per the Park Place “culture of safety” and strategic directions.
Based on assessments including RAI the Registered Nurse develops and/or revises the Resident’s individualized care plan (Residents Day), RAI care plan/Care Plan B and implements the care plans with ongoing evaluation of the Resident’s response for appropriateness and effectiveness of treatments and interventions.
Establishes and maintains therapeutic relationships with Residents and families with effective interpersonal skills ensuring Resident choice and autonomy in decision-making and care planning. Demonstrates leadership through effective collaboration with members of the interdisciplinary team to ensure consistent and comprehensive care planning that results in the delivery of safe care, grounded in Resident choice and Park Place policies and procedures.
Provides clinical leadership, guidance and direction on clinical tasks to other members of the interdisciplinary team. Leads and coordinates the flow of care and shares information collegially with other interdisciplinary team members.
Ensures pertinent health history and clinical assessment information is obtained and communicated appropriately to the Resident/ family and interdisciplinary team so that it can provide guidance to members of the team when developing the Resident’s individualized plan of care.
Documents assessments, records of observation, care provision and Resident responses according to professional standards and Park Place policies and procedures.
Initiates referrals to appropriate health care/community agencies and discusses referral information with Resident/ family and the interdisciplinary team.
Contributes to quality of care and safety assurance and improvement by participating in Park Place site committees.
Participates in quality improvement/performance measurement initiatives and processes.
a) Planning, organizing, and establishing priorities
(d) Reassigning clinical/health related tasks as necessary
(d) Utilizing infection control procedures
(Assist the Nursing Manager with orientation of employees and peers. Provides incidental or adhoc input into employee performance.
Health & Safety Responsibilities
Responsible to read, understand and comply with Park Place Seniors Living's and provincially mandated Occupational Health and Safety policies and safe work practices.
Demonstrates leadership in all aspects of the Health and Safety Program including:
o Promotes health and safety policy and awareness
Reports any near miss, injury, and accident or equipment damage to supervisor immediately and completes required reports.
Baccalaureate of Nursing or post basic course in Gerontology or two (2) years recent related experience or an equivalent combination of education, training, and experience. Ability to communicate fluently in English, both verbally and in writing.
Applies problem-solving process demonstrating critical thinking and decisionmaking skills with systems analysis.
Professionalism: Demonstrates ability to effectively establish professional working relationships with Residents and their families as well as members of the care team ensuring safe quality’ care delivery.
Change Management: Demonstrates ability to lead by effectively introducing and managing purposeful change that is consistent with Park Place’s vision, mission, and strategic directions.
Demonstrates ability to communicate effectively with Residents, families, the public, medical staff, and other members of the interdisciplinary team. Ability to intervene effectively to resolve conflict, manage stress, and work pressure.
Results Oriented: Ability to apply continuous quality improvement tools and processes within a dynamic environment, leading to improved care and service delivery.
Demonstrates applicable computer skills and knowledge of nursing-related care equipment utilization and management.
Must be able to manage stressful situations with competing priorities.
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