258 Best medical record review Jobs in Dallas, Texas (December 2025) - page 4

Registered Nurse (Full Time Nights)

1 year ago

Dallas

Job Description:\n\n Summary: Under general supervision, delivers care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation, in accordance with established protocol and / or as ordered by the emergency room physician. Works in cooperative effort with physician and other members of clinical staff to ensure effective patient care delivery and achievement of desired patient outcomes. Effectively interact with patient and significant others, while maintaining the standard of professional nursing. Provides care for patients presenting with various types of illnesses and/or injuries requiring emergency attention and must be able to recognize and effectively treat life-threatening conditions. ESSENTIAL JOB DUTIES AND RESPONSIBILITIES: FACILITY OPERATIONS Clinical 1. Provides direct and individualized nursing care to patients based on the application of scientific nursing principles. In addition to general nursing care, responsibilities include (but are not limited to): 2. Collects information regarding chief complaint and / or current symptoms, as well as a detailed patient history, and documents findings in the patient medical record. Reports findings to the healthcare provider. 3. Consults and coordinates with health care team members to assess, plan, implement and evaluate patient care plans. 4. Performs triage and assessments, while considering both physical and psychosocial elements 5. Manages basic life support needs and stabilizes patients until the attending physician is available, based upon nursing standards and protocol. 6. Initiates corrective action whenever information from monitoring equipment shows adverse symptomatology. 7. Documents nursing care as appropriate in the patient medical record. 8. Works directly under physicians, assisting them during exams, procedures, diagnostic testing and treatments. 9. Prepares and administers medications as ordered by the physician, (oral, subcutaneous, intravenous / infusion, intramuscular) and records administration and such other relative data in the medical record. Reports adverse reactions to medications or treatments in accordance with the policy regarding the administration of medications by a licensed registered nurse 10. Provides IV infusion / therapy in accordance with physician orders, performs 12-lead EKG, venipuncture and IV initiation, blood draws, cardiac and pulse oximetery monitoring, applies oxygen using the appropriate delivery system, administers nebulized treatments. 11. Assists physician with management of critical patients 12. Assists physician with procedures including but not limited to laceration repair (any complexity), any procedure requiring moderate sedation, Incision and Drainage (I &D), cardiac arrest, intubation, chest tube insertion, foreign body removal (any part of the body), live birth or spontaneous aborted fetus and tissue, records time of death and birth, assists Administration in reporting death in the emergency room as needed 13. Keeps accurate records of procedures, including moderate sedation flow sheet, CPR/Code Blue flow sheets/record 14. Maintains and makes appropriate and correct entries into applicable clinical logs and records as required by facility policy and procedure. 15. Cleans and bandages wounds, applies splints. 16. Reviews discharge instructions with the patient and, as needed, provides patient education and training including wound care, crutch training, use of nebulizers or inhalers, and other types of training. 17. Reviews all discharge instructions with patient and take vital signs prior to discharge to ensure patient is stable and records results in the patient medical record. 18. Provides basic, bedside nursing care. 19. Assists administration in maintaining proper / par-level supplies and appropriate medical equipment to care for patients. 20. Reports any suspected abuse to the appropriate agencies. 21. Initiates patient education plan, as prescribed by physician. Teaches patients and significant others how to manage their illness/injury, by explaining: discharge instructions, post-treatment home care needs, diet/nutrition/exercise programs, self administration of medication and rehabilitation, as well as provides referrals to other healthcare professionals for follow-up treatment. 22. Displays professionalism while completing multiple urgent tasks in a timely manner. 23. Records all care information concisely, accurately and completely, in a timely manner, in the appropriate format and on the appropriate forms. 24. Performs other position-related duties as assigned, depending on assignment setting. 25. Reports safety violations, work injuries, or work hazards to administration. 26. Accounts for on hand narcotics amounts at each shift change in the presence of a qualified healthcare professional, i.e., RN, physician and records narcotic count into appropriate log. 27. Logs medication inventory and removal of medications for administration as required by pharmacy policy and ensures security of the pharmacy during shift. 28. Provides proper shift change communication report to proper relief and remains on shift until properly relieved by employee of equal licensure or certification. 29. Complete all necessary chart nursing documentation in accordance with policy. Documentation must be legible and in English. 30. Performs quality assurance reviews of charts as designated by administration. 31. Maintains all required certifications and licenses as required by the 25 TAC §131.45. 32. Maintains all clinical proficiencies and annual training as required by facility policy. 33. Also performs other clinical services, where qualified and competent which may include but not be limited to the following: Laboratory a. Performs duties as assigned for venous blood draws for blood and body fluid samples. Uses drawn samples to perform and complete such laboratory point of care testing and send out labs as ordered by the on duty physician. b. Reports abnormal lab testing to the health care provider as soon as possible and without delay. c. Posts such completed lab results to the chart. d. May perform or assist with daily/monthly QC’s to ensure proper performance and compliance in the laboratory. e. Fulfills requirement of annual laboratory proficiency testing. f. Reports and documents any diversion from normal lab operations or incidents to the Nurse Director, i.e., exposures, incidents, spills, injuries, etc. COMPLIANCE 1. Maintains confidentiality of patient related issues as outlined by HIPAA and company policies. 2. Works in cooperation with other administrative and facility staff to ensure compliance with HIPAA rule and standards as applicable to patient medical records, patient care, and diagnostic testing to include but is not limited to patient medical charts, radiology reads/results and other protected health information (PHI). 3. Ensures emergency room and treatment areas operate within the compliance standard with Federal, State and if applicable, accrediting agencies. 4. Successfully completes all required competency testing as required for position with the emergency room. 5. Shall fully comply with the guidelines set forth in the Infection Control and Prevention Program and any applicable Center for Disease Control (CDC) requirements relative to the operations of the facility. 6. Reports all conditions and injury as required by state, federal and local laws including but not limited to reportable diseases, notifiable conditions, animal bites, sexual assaults, abuse, neglect and others as required by law. 7. Be required to undergo and successfully complete periodic review and on-site skill / proficiency testing. 8. Ensures operation and processes of the emergency room and treatment areas including any applicable standards of care are maintained at the highest possible level in all aspects in the areas of quality assurance, patent and life safety. RISK MANAGEMENT/QUALITY ASSURANCE 1. May assist the Nurse Director in completing or producing various clinical reports. 2. Performs medical record quality assurance reviews of nursing notes and documentation for accuracy and completion and reports deficiencies to Nurse Director. 3. Ensures all diagnostic test results and other portions of the patient char have been reviewed by the attending physician and then properly reconciled to the patient medical record. 4. Assists the Nurse Director in other clinical duties as needed. 5. Reports any violations of policies and procedure, including any incidents of over Infection Control, Patient Safety, Safety Violation and Hazards to Administration. 6. Works in cooperation with other administrative and facility staff to ensure overall departmental compliance topics and matters directly and indirectly related to quality assurance; risk management and life safety as applied to patient care and employee safety ENVIRONMENT OF CARE/LIFE SAFETY / PATIENT SAFETY 1. Abides by the Safety and Environment of Care policies and procedures of the facility. 2. Participates in disaster and fire drills as required by the facility and knows role in the event of evacuation as assigned by administration. 3. Uses proper PPE when performing patient care and handling chemicals. 4. Adheres and complies with the requirements of the infection control and patient safety programs. 5. Ensures operational readiness of the emergency room clinical department as it applies to equipment, materials, supplies, maintenance and repairs. Removes defective equipment and devices from service and makes prepares deficiency report to Nurse Director. 6. Takes steps and performs duties to ensure the emergency room nurse station and other clinical areas are clean and free from hazards. 7. May complete training and competencies in high level disinfection of semi-critical devices. 8. Properly disinfects and stores medical equipment in clean utility areas, ensures medical equipment is connected to critical power when not in use, and in ensures that all equipment is operational and ready at all times. 9. Assist in inventorying of supplies and equipment to ensure proper working order and adequate par levels. Reports low par-level of supplies and medications to Nurse Director. 10. May performs monthly inventory of medication and crash carts to ensure all medications and supplies are intact and current. Removes expired medications and orders replacement, removes any supplies with broken seals or otherwise compromised packaging and replaces the items. Properly stores or disposes of expired medications and supplies in accordance with policy. OTHER ESSENTIAL DUTIES AND JOB RESPONSIBILITIES 1. Must be adaptable to varying working conditions that may change with or without advance notice. 2. Attends monthly staff meetings, in-services and/or department meetings as required by the facility. Must attend 80% of all mandatory meetings within a one (1) year period of time. Notice of absence from any mandatory meeting must be submitted to the Nurse Director. 3. Must be able to work efficiently with various levels of management, vendors, a diverse workforce and patients from various demographic backgrounds. 4. May be required to travel at the discretion of the Governing Board. May be required to drive personal or company provided vehicles; and/or travel by airplane as needed. 5. Abides by company policies and procedures and complies with all applicable State, Federal and local laws, requirements of all Federal and State regulatory agencies and requirements of any applicable accreditation agencies. 6. Takes reasonable measures to ensure that overtime is minimized. 7. In order to ensure that department is fully operational, performs department operation duties daily and as needed. 8. Ensures that the emergency room clinical department operates within compliance with applicable policies; state, local and federal laws; applicable codes, licensing requirements; ordinances, etc. 9. Routinely participates in various activities reinforcing reasonable and sound work activities that supports the goals of the company by performing various assigned tasks. 10. Demonstrates the ability to exercise sound judgment; apply effective written and oral communication techniques with all business contacts to include but not limited to employees, vendors, other members of administration, patients, physicians and the general public. 11. In conjunction with the other administrative and other designated clinical staff, is engaged in work productivity in the freestanding emergency room. 12. Maintains confidentiality of patient and employee related issues. 13. Treat all patients, visitors, and staff members fairly and with respect. 14. Upholds and enforces patient rights. 15. Regular attendance and compliance with attendance standards is required. 16. Takes care to perform duties and task which operate within the budget set forth by the Governing Board. 17. Position is subject to require overtime. Such position may include being required to work extended hours during the week, weekends, and holidays and during periods in which a state of emergency has been declared. Competencies To perform this job successfully, an individual should demonstrate the following competencies: Analytical - Synthesizes complex or diverse information. Problem Solving - Identifies and resolves problems in a timely manner; Works well in group problem solving situations; Uses reason even when dealing with emotional topics. Technical Skills - Objectively assesses own strengths and weaknesses; Pursues training and development opportunities; Strives to continuously build knowledge and skills; Shares expertise with others. Patient/Customer Service - Manages difficult or emotional patient/customer situations; responds promptly to patient needs; solicits patient feedback in an attempt to achieve an optimum level of patient care. Interpersonal Skills - Focuses on solving conflict, not blaming; maintains confidentiality; listens to others without interrupting; keeps emotions under control; remains open to the ideas of others; and is willing to try new solutions and options. Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens for and seeks proper clarification; responds well to questions asked; demonstrates excellent group presentation skills; participates in meetings and enrichment discussions Written Communication - Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet appropriate needs; presents numerical data effectively and legibly; and is able to read and interpret written information. Teamwork - Balances team and individual responsibilities; exhibits objectivity and openness to the views of others; gives and welcomes feedback; contributes to building a positive team spirit; puts the success of the team above his/her own interests; able to build morale and group commitments to goals and objectives; s

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