Job description
- Review nurse’s notes on a daily basis for compliance with the physician’s plan of care and supplemental orders.
- Write compliance notices for any findings that are not consistent with the physician’s plan of care or clinical nursing standards as mandated by the Nurse Practice Act.
- Call nurses to set up appointments for office time to review compliance notices and documentation inconsistencies.
- Participate in in-service programs to educate nurses on documentation requirements as mandated by the agency, state and federal regulations.
- Case Conference with Case Manager nurses, DPCS and Administrator as needed to discuss patient care issues and chart review findings.
- Read all Coordination of Care notes to insure that all changes in condition have been effectively conferenced and M.D. has been notified of any changes in condition in a timely manner.
- Prepare a weekly written report of all nurses who have documentation which is “out of compliance”. A copy of this report is to be forwarded to the DPCS, Payroll and Human Resource Department.
- Review medication and treatment records for compliance with physicians’ orders, accuracy and completion. Confer with Case Manager as needed.
- Review all pre-hospitalization notes.
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