Clinical Documentation

**Division**:
Long Term Care Homes

**Temporary Duration**:
Approximate Duration: 6 Months

**About Us**:
Serving a diverse urban and rural population of more than 475,000, Niagara Region is focused on building a strong and prosperous Niagara. Working collaboratively with 12 local area municipalities and numerous community partners, the Region delivers a range of high quality programs and services to support and advance the well-being of individuals, families and communities within its boundaries. Nestled between the great lakes of Erie and Ontario, the Niagara peninsula features some of Canada’s most fertile agricultural land, the majesty of Niagara Falls and communities that are rich in both history and recreational and cultural opportunities. Niagara boasts dynamic modern cities, Canada’s most developed wine industry, a temperate climate, extraordinary theatre, and some of Ontario’s most breathtaking countryside. An international destination with easy access to its binational U.S. neighbour New York State, Niagara attracts over 14 million visitors annually, as well as a steady stream of new residents and businesses.

Please note that the Niagara Region requires that all newly hired employees are to be fully vaccinated against COVID-19 as a condition of being hired and provide proof of full vaccination, or provide proof of a bona fide medical or Human Rights Code exemption on a form issued from and approved by Niagara Region.

**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**:

- Recognized RAI credentials or equivalent.

**Knowledge**:

- At least 3 years of clinical experience within a Long-Term Care Home environment.
- At least 1 year of project management experience.
- Current regulated or licensed health care practitioner (e.g. RPN, RN, BSW, MSW, Dietitian).
- 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.

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

- Acts as systems administrator in the home for clinical documentation systems, maintaining and evaluating in-home systems, assigning and altering user rights, and ensuring system upgrades.
- Assesses issues with systems or processes and collaboratively develops solutions.
- Ensures compliance with RAI and clinical documentation processes in relation to home policies, MOHLTC regulations, College Standards and inter-RAI requirements.
- Liaises with vendors to support clinical documentation systems.

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

- Ensures that the resident assessment schedule is developed, completed and accessible to staff.
- Audits RAI and clinical documentation records for accuracy and data integrity.
- Ensures that confidentiality of staff and resident information is appropriately maintained.
- Leads RAI and clinical documentation process developments and improvements in the home, to ensure data accuracy, efficient data collection, assessment completion, and data utilization.
- Provides one-on-one support for staff struggling to document resident status and care activities.

**_ 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 in place and operating effectively.
- Ensures that monthly electronic submissions are accurate, and properly sent through to the MOHLTC.

**_ 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, including a vulnerable sector search, and submit a Canadian Police Clearance Certificate.
- Licensed health care practitioners must undertake continuing education to maintain their license.
- Regional staff strive to enable the strategic priorities of council and the organization through the completion of their work. Staff carry out their work by demonstrat