Completes nursing hx & assessment accurately within expected time frames. Determines & delivers age appropriate care. Delegates duties based on complexity of patient needsUtilizes critical thinking skills in prioritization of care. Develops & prioritizes individualized plan of care. Coordinates & collaborates plan of care with health care team. Incorporates discharge planning needs in plan of care. Documents interventions that are accurate, pertinent, timely & legible. Administers meds observing the “5 rights”Administers meds correctly based on pt’s age & clinical condition. Performs skills & tasks required by unit expectations. Provides safe environment. Demonstrates correct use/troubleshooting equipment. Evaluates the efficacy of plan of care. Modifies based on pt’s current condition. Ability to supervise staff members who provide direct pt care. Provides health care at the best value without compromising pt care. Responsible & accountable for all actions. Practices within the scope of license. Regularly attends department meetings (10 out of 12). Accesses and monitors hospital e-mail. Provides care to patient prior to procedure & verifies required consents, diagnostic tests, and documentation are present & reviewed prior to case start. Collects and analyzes cardiovascular, respiratory, & body temp data. Promotes fluid balance and prevents complications resulting from abnormal or undesired fluid levels. Monitors airway for patency & adequate exchange with appropriate intervention when required by patient condition. Recognizes & facilitates treatment of abnormal cardiac rhythms. Alleviates and reduces pain to a level of comfort acceptable to patient without loss of patient’s protective reflexes, utilizes appropriate pain assessment tool. Assists physicians with diagnostic or therapeutic procedures. Obtains, labels and documents specimens obtained according to P&P. Utilizes established criteria to determine patient readiness for discharge. Safely and proficiently accesses peripheral veins for the purpose of obtaining blood for diagnostic testing or initiating IV therapy. EKG: correctly applies leads and performs test accurately for interpretation. Utilizes 2 identifiers for proper patient identification. Verifies surgical site/procedure per patient/family, H&P, order, consent, and surgical schedule. Correctly demonstrates, performs & documents “Time Out” when applicable. Correctly demonstrates, performs & documents effective communication between caregivers i.e. Read Back & Verify/RBV standard, critical results, etc. Accurately & completely performs & documents Medication Reconciliation process. Completes annual hospital and department required competencies. Organizes and participates in committees and education programs in support of PI. Develops effective data collection, organization, and evaluation tools/systems for monitoring quality care. Summarizes collected data; reports findings and recommendations in a timely manner; communicates PI outcomes. Assists in evaluation of grievances to identify ways to improve patient care and standards. Keeps facility current on state and federal rules and regulations and accrediting body requirements. Competently responds to emergency situations. Demonstrates high level of accuracy and attention to detail in preadmission requirements. Demonstrates punctuality and ability to meet deadlines. Contributes to evaluation of quality systems and recommends appropriate revisions. Maintains work orders and keeps log of pending and completed requests. Maintains maintenance inspection log weekly, quarterly, monthly. Serves as liaison with outside contractors, environmental services, maintenance, and various depts. As well as physician offices.Maintains forms database for the facility.
This is a general job description, and not necessarily an extensive list of all responsibilities, skills, duties, requirements, or working conditions associated with the position. While this is intended to be an accurate reflection of the current position, management reserves the right to revise the job or require that other or different tasks be performed when circumstances change (i.e., emergencies, changes in personnel, workload, or technical developments). Essential Job Functions 1. Places the patients in the examination room. Takes histories and physical exam information. Obtains vital signs, ascertains patient complaint or reason for visit and enters the information into the patient’s record. Checks the patient record to insure all required information has been obtained and completed. 2. Completes disability status sheet and fax to proper places, as requested. 3. Writes school/work excuses and provider orders, and has provider sign. 4. Prior to patient visit, performs the following: a. Ensures that all equipment in exam room is clean and properly set up. b. Ensures supplies are adequate. 5. Cleans and restocks examination rooms for the day’s use. Reviews patient records, x-rays, and test results for the day’s visit and prepares necessary paperwork. 6. Accompanies the provider while seeing patients, when appropriate. 7. Screens telephone calls for the provider, and takes clinical messages, as appropriate. 8. Answers patient inquiries with respect to medical questions within the scope of practice and practice policy. 9. Takes calls from the pharmacist. Calls or electronically submits prescriptions and prescription refills to pharmacy as directed by the provider. 10. Coordinates diagnostic and laboratory services for patients on an outpatient basis such as PT, MRIs, Bone Scans, CTs, etc. and completes proper paperwork. 11. Assists provider in examination and surgical or diagnostic procedures and treatment, as well as preps patients. 12. Marks superbill or documents EHR for any procedures and injections performed and any supplies used. 13. Makes arrangements with proper agencies for administration of patient home health care as directed by provider. 14. Coordinates provider referrals to other providers and relays proper information about the patient. 15. Maintains all clinical equipment to include sterilizing, as applicable. Evaluates all equipment for damage or maintenance needs, and reports information to the Practice Manager. 16. Checks clinical supplies and initiates the ordering process. 17. Via electronic, paper or other forms of receipt reviews and completes clinical mail for the provider when appropriate/authorized. 18. Prepares patient insurance forms completely prior to giving to provider for review and signature.
