Certified Case Manager (CCM), Discharge Plans, Documentation, Medical Records, Patient Assessment, Patient Care, Patient Charts, Patient Education, Problem Solving Skills, Record Keeping, Registered Nurse (RN), Treatment Plan
LOCATION
Harvey, IL
POSTED
30+ days ago
Essential Job Functions "Conducts an initial patient/family assessment on every inpatient to determine psycho-social needs and discharge plans and completes Care Coordination Assessment within the first 48 hours of admission to determine need for Care Coordination intervention. "Performs documentation on a weekly basis in patients' medical charts. Documentation shall include significant patient data, problems defined, assessment goals, treatment plans, date and action taken, summary of same and follow-up activities when indicated. Documentation shall occur more frequently if the situation changes. "Participates as a member of the Multidisciplinary Rounds. "Performs a consultative role with staff regarding patients/families. "Communicates clinical status updates to patients/families and other involved individuals. "Regularly evaluates the appropriateness of the treatment plan in relation to the progress of the patient toward the attainment of stated goals and communicates such with patient and/or family. "Reviews final discharge plans and instructions with patient, family, or responsible party, evidenced by documentation in the patient's medical chart. "Keeps record on each patient with discharge date and any service patient was referred. This information will be documented in the medical record. "Performs responsibility of discharge planning for the patient/family and coordinates the discharge plan with the entire rehabilitation team.