Nursing documentation jobs

Provide comprehensive nursing care to ambulatory patients, coordinating with physicians and health team members to implement treatment plans and ensure quality outcomes.

Compensation

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.

Responsibilities

Conduct comprehensive health assessments across all body systems
Document and communicate patient physiologic and psychosocial status
Develop and implement individualized care plans
Administer medications and wound care safely
Provide patient and family education and discharge planning

Requirements

Bachelor’s Degree in Nursing
Nice to have: specialized nursing certifications

Skills

patient assessment nursing documentation medication administration wound care patient education clinical judgment

Registered Nurse

Gentiva · Posted Nov 10, 2024

Open

Jasper, Indiana, United States
Competitive Pay
1+ years

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Provide skilled nursing care and case management for hospice patients in their homes or assisted living settings.

Responsibilities

Be the primary point of contact for patients and families
Deliver and document skilled nursing care
Perform initial and ongoing assessments
Collaborate with interdisciplinary team
Provide emotional, physical, and spiritual support

Requirements

Registered Nurse
Nice to have: hospice or palliative care experience

Skills

patient assessment nursing documentation interdisciplinary collaboration regulatory compliance communication nursing assessment tools computers facsimile equipment

Licensed Practical Nurse (LPN)

Bethesda Health Group · Posted Nov 9, 2026

Open

Bethesda, Maryland, United States
Full-time · Associate
$27–$43 per hour

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Provides basic nursing care by assisting in the assessment of the resident on admission and on an ongoing basis.

Compensation

Pay range: $26.96- $43.25 per hour

Responsibilities

Assists in assessment of residents on admission and ongoing basis
Communicates significant changes to interdisciplinary team
Accurately documents all assessments
Participates in care planning process
Updates care plan when needed

Requirements

Licensed Practical Nurse from an accredited school of nursing
Nice to have: long-term care experience

Skills

basic nursing care assessment documentation medication administration IV fluid administration critical thinking SBARR communication

West Admissions RN

Four Seasons, The Care You Trust · Posted Nov 10, 2026

Open

Franklin, North Carolina, United States +1 more
Full-time

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Ambassador of Four Seasons mission to enable patients to take full advantage of their hospice benefit by performing admissions and providing direct nursing care.

Locations (2)

Franklin, North Carolina, United States
North Carolina, United States

Responsibilities

Perform 2-4 admissions daily depending on shift and patient complexity
Perform patient visits and direct nursing care as needed
Conduct comprehensive patient assessments
Educate patients and families
Maintain business partnerships with referral sources

Requirements

Nice to have: Two years of clinical experience

Skills

Clinical nursing care Patient assessment

Licensed Practical Nurse (LPN)

365 Health Services · Posted Nov 9, 2026

Open

Feasterville, Pennsylvania, United States
On-site
Full-time
Salary: Based on Experience

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Provide skilled nursing care to clients in their homes throughout Eastern Pennsylvania, monitoring health status, administering medications, and collaborating with the healthcare team.

Responsibilities

Provide skilled nursing care to clients in accordance with their individualized plan of care, physician orders, and applicable nursing standards.
Perform nursing assessments and monitor clients' overall health status, identifying and reporting changes in condition promptly.
Administer medications and treatments as prescribed and within the scope of LPN practice.
Monitor and document vital signs, including blood pressure, pulse, temperature, respirations, and oxygen saturation as appropriate.
Provide wound care, dressing changes, and other prescribed nursing treatments.

Requirements

Licensed Practical Nurse (LPN) license in the Commonwealth of Pennsylvania
Nice to have: previous home health
Nice to have: home care
Nice to have: clinical nursing experience

Skills

clinical assessment critical-thinking problem-solving medication administration

Licensed Practical Nurse (LPN)

365 Health Services · Posted Nov 9, 2026

Open

North Philadelphia, Pennsylvania, United States
On-site
Salary: Based on Experience

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Provide skilled nursing care to clients in their homes throughout Eastern Pennsylvania.

Responsibilities

Provide skilled nursing care to clients in accordance with their individualized plan of care, physician orders, and applicable nursing standards.
Perform nursing assessments and monitor clients' overall health status, identifying and reporting changes in condition promptly.
Administer medications and treatments as prescribed and within the scope of LPN practice.
Monitor and document vital signs, including blood pressure, pulse, temperature, respirations, and oxygen saturation as appropriate.
Provide wound care, dressing changes, and other prescribed nursing treatments.

Requirements

Current and unrestricted Licensed Practical Nurse (LPN) license in the Commonwealth of Pennsylvania
Nice to have: previous home health, home care, or clinical nursing experience

Skills

clinical assessment critical-thinking problem-solving medication administration

Stepdown Medicine Nurse BWH

Mass General Brigham · Posted Nov 9, 2026

Open

Boston, Massachusetts, United States
On-site
Full-time · Associate
$42–$106 per hour

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Registered Nurse responsible for planning and providing patient care in stepdown medicine at Brigham and Women’s Hospital

Compensation

$41.71 - $105.65/Hourly

Responsibilities

Plan and provide patient care
Assess, plan, implement and evaluate patient care
Maintain continuity of care
Document patient care
Develop comprehensive care and discharge plans

Requirements

Bachelor of Science Degree in Nursing
Nice to have: Stepdown medicine experience

Skills

Nursing care Patient assessment Care planning Medication administration Nursing documentation Infection control Universal precautions

Benefits

Registered Nurse - Outpatients

Harbour Hospital · Posted Nov 9, 2026

Open

Poole, England, United Kingdom
Full-time
£41K per year

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Compensation

Salary: Up to £41,000.00 per year (depending on level of experience, training and qualification)

Responsibilities

Deliver direct nursing care in line with patient care plans and clinical protocols.
Assess patient needs, prioritise care, and update care plans accordingly.
Monitor vital signs, recognise changes in condition, and escalat[e] appropriately using clinical judgement.
Administer medications safely and effectively in accordance with hospital policies and the NMC Code.
Maintain accurate, legible, and timely nursing documentation, including assessments, care plans, and observations.

Requirements

Registered Nurse (Adult) with valid NMC registration
Nice to have: Previous experience in relevant specialty (e.g., surgical, medical, outpatient, orthopaedics, critical care)

Skills

Nursing care Patient care plans Clinical protocols Vital signs monitoring Medication administration