Job Title

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 ord...