The Interprofessional Documentation Specialist (IDS) is a Registered Nurse (RN) who serves as a key member of the Interprofessional team at Mary Free Bed (MFB) Rehabilitation Hospital. Integrating excellent communication skills, leadership, decision-making abilities, advanced knowledge, evidence-based practice, and clinical skills, the IDS continuously strives for improvements in the delivery and outcomes of patient care. Due to expertise in the electronic medical record, the IDS also provides support in all areas of documentation for both licensed and unlicensed staff to meet accreditation requirements and maintain patient safety. In addition, the IDS serves as role model of professional conduct and plays a vital role in creating a professional climate at MFB to meet our diverse needs.
Essential Job Responsibilities:
- Interprofessional Documentation Specialist/Responsibilities:
- Monitors, evaluates, and reports performance on key quality indicators including but not limited to fall prevention, skin breakdown prevention, pain documentation/control, VTE prophylaxis, restraint usage, sedation, return to acute, and hypoglycemia protocol compliance.
- Develops strong partnerships with the leadership team to drive evidence-based practice initiatives that support improved patient outcomes.
- Monitors compliance in best practice initiatives through chart audits, regular report gathering and analyzing, and manual tracking as needed.
- Develops proficiency in supporting the key principles and behaviors of High Reliability.
- Develops proficiency in key change management principles to support the implementation of evidence-based initiatives.
- Serves as the subject matter expert when appropriate to support the development of evidence-based policies, procedures, and protocols.
- Provides leadership to the interprofessional healthcare team to develop, implement and evaluate new patient care programs and outcome goals specific to the patient population.
- Teaches at new hire orientation for interprofessional team members including but not limited to nursing, therapy, providers.
- Serves as a resource for all staff to support thorough documentation that meets compliance and regulatory standards.
- Supports the staff at Mary Free Bed with new changes to the electronic medical record by reinforcing education and providing at-the-elbow assistance as needed.
- Supports staff competency regarding documentation to assure that the documentation meets regulatory and accreditation requirements and is in alignment with recognized standards of care and best practice benchmarks.
- Provides occurrence report support for directors and providers.
- Supports policy development.
- All other duties as assigned.
Commitment to Diversity, Equity and Inclusion
Embrace Diversity, Equity and Inclusion, by:
- Treating everyone with dignity and respect
- Opening more doors to opportunities for underrepresented cultures
- Growing talent and people
- Evaluating and eliminating disparities
- Taking action against injustices, bias and racism
- Honoring our differences and how to collaborate
- Educating staff, patients and the communities we care for
- Restoring Hope and Freedom, together
Essential Job Qualifications (Knowledge, Education, and Training Requirements):
- Licensure Requirements: Registered Nurse in the State of Michigan.
- Education: BSN or bachelor's degree in related field.
- Current Basic Life Support (BLS) certification
- EPIC for the Clinical Informaticists certification - Have or obtain within 6 months of hire
- Must have 3-5 years of relevant nursing experience.
- Must be proficient in clinical nursing documentation in an electronic medical record. Specific training in clinical informatics is preferred but not required.
- Proficient computer skills: Microsoft Office programs
- Strong critical thinking, decision-making, delegation, and leadership skills are required.
- Time management and organizational skills are very important, as well as effective written and verbal communication skills.
- Must be able to work effectively under time requirements and deadlines, problem-solve when facing unexpected issues, handle interruptions and prioritize effectively.
- Physical Demands/Work Environment:
- The physical ability to lift, position, and transport patients
- The ability to frequently sit, stand, walk, bend, kneel, twist, crawl, grasp, reach, and occasionally climb
- The ability to hear, speak, write, and see (correctable vision)
- The ability to frequently lift to 35 pounds, and occasionally lift more than 35 pounds
- The ability to occasionally push, pull, or carry weight anywhere from 1 to 100+ pounds while assisting patients and moving equipment
- Due to possible exposure to blood-borne pathogens and hazardous materials, must be able to understand and follow department policies related to employee safety.
- Must be competent with computer systems for documenting patient care.
Mary Free Bed is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, national origin, age, genetic information, veteran status, disability or other legally protected characteristic.