RN per diem

About the role

Charting and Documentation * Complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge. * Encourage attending physicians to review treatment plans, record and sign their orders, progress notes, etc., in accordance with established policies. * Receive telephone orders from physicians and record on the Physicians' Order Form. * Transcribe physician's orders to resident charts, cardex, medication cards, treatment/care plans, as required. * Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. * Fill out and complete accident/incident reports.

Submit to Director as required. * Chart all reports of accidents/incidents involving residents. Follow established procedures. * Record new/changed diet orders.

Forward information to the Food Services Department. * Report all discrepancies noted concerning physician's orders, diet change, charting error, etc., to the Nurse Supervisor. * Fill out and complete transfer forms in accordance with established procedures. * Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established procedures. * Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. * Sign and date all entries made in the resident's medical record.

Drug Administration Functions * Prepare and administer medications as ordered by the physician. * Verify the identity of the resident before administering the medication/treatment. * Ensure that prescribed medication for one resident is not administered to another. * Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents.

Report needs to the Nurse Supervisor. * Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies. * Ensure that narcotic records are accurate for your shift. * Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. * Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. * Notify the attending physician of automatic stop orders prior to the last dosage being administered. * Dispose of drugs and narcotics as required, and in accordance with established procedures.