Facilitates the improvement of the overall quality and completeness of clinical documentation in the patient record through extensive interaction with physicians, nursing staff, other patient caregivers, and HIM coding staff. Ensures that the medical record documentation provides an accurate representation of the patient's clinical care, diagnosis, severity, and expected risk of mortality sufficient to support DRG assignment.
Provides individualized education, psychosocial support and exercise training to patients receiving cardiac or pulmonary rehabilitation in collaboration with the medical directors and the multidisciplinary team. Uses nursing process to assess, plan, implement and evaluate patients. Assesses educational needs and provides disease specific education. Maintains a safe and clean environment for patients.
Functions as a resource to physicians, nurses, patients, and families specializing in the care of patients with disorders of the gastrointestinal, genitourinary, and integumentary systems. Functions as an independent practitioner in the assessment, implementation, and revision of plans of care for patients with wounds, ostomies, fistulas, incontinence issues, and management of patients undergoing negative pressure wound therapy. Participates in the development of pressure injury prevention programs, process improvement initiatives, skin and wound care guidelines, patient and staff education, coordination of services, guidelines for specialty bed usage and development of a product formulary within the institution.