Registered Nurse - Clinical Documentation

Are you a highly skilled and compassionate Registered Nurse looking for a new opportunity? Come join the team at Orlando Health as a Clinical Documentation Nurse! Our successful candidate will have a strong clinical background and a passion for accurate and thorough documentation. As the Clinical Documentation Nurse, you will play a vital role in ensuring the quality and integrity of patient records, ultimately impacting the overall delivery of patient care. If you are a detail-oriented professional with a dedication to providing exceptional patient care, we want to hear from you!

1. Accurate and thorough documentation of patient records: The Clinical Documentation Nurse will be responsible for ensuring the accuracy and completeness of patient records, including medical histories, treatment plans, and progress notes.
2. Compliance with documentation standards: This role will require the candidate to have a strong understanding of documentation standards and guidelines set by regulatory bodies, and to ensure that all records meet these requirements.
3. Communication with healthcare team: The Clinical Documentation Nurse will collaborate with other healthcare professionals, such as physicians and case managers, to gather information and ensure the accuracy of patient documentation.
4. Identifying and resolving documentation discrepancies: The successful candidate will be expected to identify and resolve any discrepancies or missing information in patient records, ensuring the highest level of accuracy and completeness.
5. Educating staff on documentation best practices: The Clinical Documentation Nurse will be responsible for educating and training other healthcare staff on proper documentation practices to improve overall quality and accuracy.
6. Continuous review and improvement of documentation processes: This role will require the candidate to continuously review and improve documentation processes to ensure efficiency and accuracy.
7. Maintaining patient confidentiality: The Clinical Documentation Nurse must adhere to strict confidentiality guidelines and ensure that all patient records are kept confidential and secure.
8. Quality improvement initiatives: The successful candidate will participate in quality improvement initiatives to enhance the overall quality of patient care delivery by ensuring accurate and complete documentation.
9. Strong clinical knowledge and expertise: The Clinical Documentation Nurse should have a strong clinical background and knowledge of medical terminology, procedures, and treatments to accurately document patient information.
10. Compassionate and patient-focused approach: As a representative of Orlando Health, the Clinical Documentation Nurse should demonstrate a compassionate and patient-focused approach, ensuring that all documentation accurately reflects the patient's needs and concerns.

According to JobzMall, the average salary range for a Registered Nurse - Clinical Documentation in Orlando, FL, USA is $73,900 - $92,400 per year. Factors such as experience, education, and specific job responsibilities can affect the salary range for this position.

Orlando Health is a private, not-for-profit network of community and specialty hospitals based in Orlando, Florida. Orlando Health has award-winning hospitals, clinics and over 2000 physicians throughout Central Florida.