Clinical Documentation

2 weeks ago

Niagara, Canada Niagara Region Full time

**Division**:
Long Term Care Homes

**Job Summary**:
Reporting to the Supervisor Clinical Documentation & Informatics, the Clinical Documentation & Informatics Lead is responsible for maintaining the homes clinical documentation system, and electronic Resident Assessment Instrument (RAI) system, ensuring that the systems are managed in a manner that is compliant with Provincial and Regional Standards, related legislation and polices.

**Education**:

- Current regulated or licensed health care practitioner (e.g. RPN, RN, BSW, MSW, Dietitian).
- Recognized RAI credentials or equivalent.
- Adult Education Certificate an asset.

**Knowledge**:

- At least 3 years of clinical experience within a Long-Term Care Home environment.
- At least 1 year of project management experience.
- Excellent knowledge and experience with adult education strategies/facilitation.
- Excellent knowledge and experience with computerized clinical documentation systems and RAI is required.
- Certificate in Adult Education or Training is preferred.
- Knowledge of interdisciplinary team members, Ministry documentation standards and home policies on assessment and care planning is preferred.
- Proficiency with Point Click Care.
- Demonstrated Leadership and Communication skills preferred.
- Knowledge and understanding of The Personal Information Protection and Electronic Document Act (PIPEDA).

**Responsibilities**:
**_ Maintains the home’s clinical documentation system, and electronic Resident Assessment Instrument (RAI) system. (15% of time)_**:

- Conducts audits of the Point Click Care EMR system to ensure accuracy and compliance.
- Acts as the systems administrator for clinical documentation systems, managing in-home system functionality, assigning, and modifying user access, and overseeing system upgrades with support from Supervisor of Clinical Documentation and Informatics.
- Identifies issues with systems or processes and collaborates with relevant teams to develop effective solutions with support from Supervisor of Clinical Documentation and Informatics.
- Ensures compliance with RAI and clinical documentation procedures in accordance with home policies, MOHLTC regulations, College Standards, and interRAI requirements.
- Works closely with vendors to ensure ongoing support and optimization of clinical documentation systems in collaboration and support from Supervisor of Clinical Documentation and Informatics.

**_ Ensures the timely completion of MDS assessments, resident assessment protocols, and care plans. (40% of time)_**:

- Develops and maintains the resident assessment schedule, ensuring it is completed on time and accessible to staff.
- Audits RAI and clinical documentation records to verify accuracy and ensure data integrity.
- Safeguards the confidentiality of staff and resident information, ensuring compliance with privacy standards.
- Leads the development and improvement of RAI and clinical documentation processes within the home, focusing on data accuracy, efficient data collection, timely assessment completion, and effective data utilization.
- Ensures the accurate completion or delegation of all MDS assessments, including those for Significant Change in Status.
- Oversees the Electronic Medical Record (EMR) processes within the home.
- Serves as the primary point of contact for Point Click Care and all documentation-related processes in the home.
- Collaborates with the leadership team to support all operational processes.
- Provides regular communication and support to staff regarding updates or changes to EMR software, processes, or clinical assessments.
- Supports and facilitates compliance with clinical documentation and care planning procedures, ensuring adherence to applicable college standards (e.g., College of Nurses).
- Facilitates training for new hires and conducts annual refresher courses on assessments, processes, and navigation of the Point Click Care EMR.
- Collaborates with the interdisciplinary team to develop and implement therapeutic care plans, focusing on goals, interventions, clinical assessments, and documentation.
- Provides on-the-spot support to staff with clinical assessments, documentation, and care planning.

**_ Analyzes management information and generates regular reports from the MDS-RAI, and other relevant systems, to be used in clinical and management decision-making. (20% of time)_**:

- Ensures that data submission requirements and processes are established and functioning effectively.
- Verifies that monthly electronic submissions are accurate and correctly transmitted through the EMR to the appropriate repository for acceptance.

**_ Provides input on staff performance to accountable managers for staff appraisal purposes, participating in transfer, promotion, demotion, and discipline decisions. (5% of time)_**:
**Special Requirements**:

- In accordance with the Corporate Criminal Record Check Policy, the position requires the incumbent to undergo a Criminal Records Check,

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