About the job
- Efficiently completes essential medical documentation including QA reports, evaluations, charting, and 24-hour reports for the Director of Nursing (DON) as well as forms required for admissions, transfers, discharges, and incident reports, ensuring that all pertinent information is accurately documented in resident care notes and effectively communicated to caregiver staff.
- Conducts thorough monthly reviews of kardexes to verify the completeness and accuracy of information, ensuring physician orders are transcribed correctly and that stop order policies are adhered to.
- Regularly assesses caregiver interdisciplinary progress notes to confirm they are detailed and informative regarding the care provided, reflect the resident’s responses to care, honor the resident’s wishes, and comply with regulatory requirements.

