Medical Records - LVN

Description

JOB DESCRIPTION

JOB TITLE: Medical Records-LVN

JOB CODE:

DEPARTMENT: NURSING

FLSA STATUS: NON-EXEMPT

REPORTS TO: DIRECTOR OF NURSING

DATE OF LAST UPDATE: 04/16/2026

JOB SUMMARY: Under the supervision of the Director of Nursing nurse, performs a variety of clinical administrative duties associated with patient care unit operations. Responsible for providing nursing care to residents as prescribed by the physician and in accordance with standards of nursing practices, regulations, and directed by the Director of Nursing.

ESSENTIAL FUNCTIONS:

• •Written and verbal communication with members of the healthcare team, patients, and visitors utilizing equipment such as the telephone
• •Maintain confidentiality of patient information
• •Assemble, complete, and process patient charts as indicated
• •Keep patient records accurately identified; maintain an accurate clinical record, recording information per facility policy
• •Transcribe doctors’ orders per facility policy accurately and promptly implement physicians’ orders
• •Perform daily review of charts for incomplete histories and operative summaries; bringing any compliance issues to the attention of the appropriate member of the health care team for correction
• •Obtain closed records from Medical Records as needed
• •Initiate required nursing forms for new admissions
• •Order unit supplies to maintain inventory stock and supplies; assist with receiving, distributing and sorting supplies brought to the unit
• •Enter, transcribe, and confirm all doctor/hospital admission orders for new admissions to community
• •Support and enforce infection-control policies and procedures
• •Consistently follow established standards, policies, and procedures in providing nursing care
• •Accept accountability for clinical care of assigned patients, including supervision of nonprofessional personnel
• •Support standards of nursing care through adherence to existing policies and procedures
• •Seek guidance when encountering nursing procedures and responsibilities that have not been mastered
• •Promote positive public relations with patients, residents, family members, and guests
• •Use tactful, appropriate communications in sensitive and emotional situations
• •Use appropriate workplace behavior and adhere to dress code at all times
• •Understand and adhere to the guidelines of “Residents Rights” and assure resident safety

Requirements

QUALIFICATIONS:

Required

• •Current LVN license
• •CPR certified required; 30 days will be given to complete a course and get certified
• •Ability to understand, remember and carry out verbal or written instructions in English
• •Ability to complete assignments in a timely manner
• •Ability to be flexible and positive with intermittent interruptions

Preferred:

2 years nursing experience in long term care/skilled nursing

PHYSICAL REQUIREMENTS: The ability to safely perform movements such as pushing, pulling, lifting, bending, kneeling, and reaching up to 50 pounds with or without reasonable accommodations

WORK SCHEDULE: As assigned, including some weekends, evenings and holidays

WORK ENVIRONMENT: Clinical

Caraday Healthcare provides equal employment opportunities (EEO) to all team members and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, genetics, or any other characteristic protected by law.