Licensed Practical Nurse

Licensed Practical Nurse (LPN) – Clinical Documentation & Patient Intake

We are seeking a dependable, detail-oriented Licensed Practical Nurse (LPN) to join our clinical team in a Clinical Documentation & Patient Intake role. This position plays an important part in ensuring each patient encounter begins with accurate, thorough, and organized clinical information.

The ideal candidate is an experienced LPN who is comfortable speaking with patients, obtaining detailed medical histories, reviewing medications and previous treatment, taking vital signs, and accurately documenting information in the Electronic Health Record (EHR).

Strong documentation, communication, organization, and computer skills are essential for this position.

• Greet patients and assist with efficient patient flow through the clinical area.

• Obtain and accurately document patient vital signs, including blood pressure, pulse, respirations, temperature, weight, and other measurements as required.

• Conduct detailed patient intake interviews and accurately document information in the EHR.

• Obtain and document a thorough History of Present Illness (HPI), including current symptoms, pain complaints, onset, duration, severity, aggravating and alleviating factors, previous treatment, and response to treatment.

• Review and update past medical history, surgical history, social history, family history, allergies, and other pertinent clinical information.

• Perform and document an accurate Review of Systems (ROS).

• Complete medication reconciliation at each applicable visit, including medication name, dosage, frequency, effectiveness, side effects, and changes since the previous visit.

• Review the patient's medical record prior to and during intake to identify information requiring clarification or updating.

• Document previous procedures, diagnostic testing, imaging, specialist care, hospitalizations, and other relevant treatment when applicable.

• Identify discrepancies or missing information in the medical record and obtain clarification from the patient when appropriate.

• Ensure clinical documentation is complete, accurate, organized, and ready for provider review.

• Prepare patient encounters within the EHR and ensure required documentation is entered in the appropriate sections of the medical record.

• Communicate pertinent patient concerns, changes in condition, abnormal vital signs, or other significant findings to the provider.

• Assist providers and other clinical staff with patient care and clinical workflow as needed.

• Respond appropriately to patient questions and communicate provider instructions within the scope of the LPN role.

• Assist with prescription refill requests, orders, forms, medical record requests, and other clinical documentation as assigned.

• Maintain accurate and timely documentation in accordance with organizational policies and applicable federal and state requirements.

• Maintain strict patient confidentiality and comply with HIPAA requirements at all times.

• Participate in chart review, documentation quality improvement, and clinical workflow initiatives as assigned.

• Maintain a professional, organized, and patient-centered clinical environment.

• Perform other clinical and administrative duties as assigned.

Clinical Documentation – Demonstrates the ability to obtain detailed and relevant information from patients and translate that information into clear, accurate, and organized EHR documentation.

Attention to Detail – Carefully reviews patient information and identifies inconsistencies, missing information, medication changes, and other details requiring clarification.

Communication – Communicates professionally and effectively with patients, providers, coworkers, and other healthcare…