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 orders, diet change, charting error, etc., to the Nurse Supervisor. • Fill out and complete transfer forms in accordance with established procedures. • Ensure that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established procedures. • Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. • Sign and date all entries made in the resident's medical record. Drug Administration Functions • Prepare and administer medications as ordered by the physician. • Verify the identity of the resident before administering the medication/treatment. • Ensure that prescribed medication for one resident is not administered to another. • Ensure that an adequate supply of floor stock medications, supplies, and equipment is on hand to meet the nursing needs of the residents. Report needs to the Nurse Supervisor. • Order prescribed medications, supplies, and equipment as necessary, and in accordance with established policies. • Ensure that narcotic records are accurate for your shift. • Notify the Nurse Supervisor of all drug and narcotic discrepancies noted on your shift. • Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop order policies. • Notify the attending physician of automatic stop orders prior to the last dosage being administered. • Dispose of drugs and narcotics as required, and in accordance with established procedures.

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