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Medical Records Nurse

2 months ago

Raleigh NC, United States Duke Health Full time

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together. About Duke Raleigh Hospital, A Campus of Duke University Hospital Pursue your passion for caring with the Duke Raleigh Campus in Raleigh, North Carolina, which has been part of Duke Health since 1998 and has served Wake County for more than 35 years. Duke Raleigh Campusfeatures 204 inpatient beds and offers a comprehensive array of services, including cancer, cardiovascular, neuroscience, advanced gastrointestinal, and wound healing care.
Duke Nursing Highlights:
* Duke University Health System is designated as a Magnet organization
* Nurses from each hospital are consistently recognized each year as North Carolina's Great 100 Nurses.
* Duke University Health System was awarded the American Board of Nursing Specialties Award for Nursing Certification Advocacy for being strong advocates of specialty nursing certification.
* Duke University Health System has 6000 + registered nurses
* Quality of Life: Living in the Triangle
* Relocation Assistance (based on eligibility)
Registererd Nurse (RN) - Progressive Care Unit
Full time position: 12 hour shifts 3x a week
**The Progressive Care Unit is a step down unit for ICU. The patient population on this unit includes patients with altered mental status, DKA, respiratory failure, post cardiac catheterization, and some post-surgery patients. This is a fast paced unit where nurses have the opportunity to learn advanced skills, such as management of drips including Cardizem, Heparin, and Insulin
Independently plan and provide professional nursing care for patients in accordance with physician orders and established policies and procedures. Provide nursing services to patients and families in accordance with the scope of the RN as defined by the North Carolina Board of Nursing.
Plan, provide, supervise and document professional nursing care utilizing the nursing process for patients in accordance with physician orders and established policies and procedures. Use professional nursing judgment to individualize the plan of care based on assessment of the patient's baseline needs and response to care.
* Delegate tasks and supervise the activities of other licensed and unlicensed care providers.
* Assist other nursing personnel in the delivery of nursing care and act as team leader or charge nurse for a group of patients or an entire unit as assigned.
* Monitor and initiate corrective action to maintain the environment of care including equipment and material resources.
* Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
* Act as preceptor and support the development of other staff and formal learners.
* Participate in the identification of clinical or operational performance improvement opportunities and in performance improvement activities.
* Work requires graduation from an accredited BSN or ADN program.
Registered nurses hired between July 1, 2014 and April 11, 2021 without a Bachelor's degree in Nursing (or higher) are encouraged to enroll in an appropriate BSN program within two years of their start date but must complete the program within five years of their start date. Knowledge of scope of the registered nurse, licensed practical nurse and unlicensed staff
* Knowledge of and appropriate application of the nursing process
* Ability to assess nursing needs of acute and chronically ill patients and their families
* Ability to communicate clearly with patients, families, visitors, healthcare team, physicians, administrators, leadership and others
* Ability to teach patients and families in accordance with the nursing plan of care
* Ability to record activities, document assessments, plan of care, interventions, evaluation and re-evaluation of patient status
* Ability to use computer and learn new software programs
* Able to document and communicate pertinent information using computer and/or paper documentation tools
* Ability to navigate the entity to provide clinical care for patients
* Working knowledge of infection control procedures and safety precautions
* Working knowledge and completion of appropriate The Joint Commission (TJC) and other regulatory requirements
* Pre-employment Physical Capacity Testing Required
Duke University is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.
Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.
Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities.