Job Description

LPN- Assisted Living

• Completes and files required recordkeeping forms/charts upon the resident’s admission, transfers/ and /or discharge.

• Directs attending physicians in reviewing service plans, recording and signing orders, progress notes, etc., in accordance with established policies.

• Receives telephone orders from physicians and record on the physicians’ order form.
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• Oversees accurate transcription of physicians orders to resident charts, cardex, medication cards, treatment/care plans, as required.

• Reviews clinical documentation to ensure it is accurate and complete. Documents in the medical record.

• Records new/changed diet orders. Forwards information to Dietary Department.
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• Resolves discrepancies concerning physicians orders, diet change, charting errors, etc.

• Ensures that appropriate documentation concerning unauthorized discharges is entered in the resident's medical record in accordance with established policies.

1. Checks all entries made in the resident's medical record for correct dates and times.
2. Facilitates completion of advance directives.
3. Supervision of Charge Nurses giving medication
4. Cleans or delegates cleaning of medication carts monthly and prn; has cleaning schedule initialed by charge nurse.

1. Checks narcotic count three times weekly for accuracy.
2. Performs routine audits on all shifts for nurses giving medications.
3. Disposes of drugs and narcotics as required.
4. Administers medications when necessary, following all procedures of the Home.

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