Medical Records

4 weeks ago

Gettysburg PA, United States WellSpan Health Services Full time

Schedule
Monday - Friday 8am - 5pm
General Summary
Provides direct patient care at an intermediate practitioner level, normally in an outpatient setting. Assesses patients, performs treatments, administers medications and instructs patients and their families in appropriate care. May require specialized skills and training depending on work area assignment.
Duties and Responsibilities
Essential Functions:
Provides direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care.
Writes initial nursing histories, assesses patients' conditions and develops individual care plans for patients.
Prepares patients for scheduled procedures to assist in patient assessment.
Assists physicians with examinations, procedures and other processes related to direct patient care.
Arranges for patients' ordered diagnostic and therapeutic services.
Monitors and ensures accuracy of recording on patient medical records. Maintains all required reports, records, statistics, etc..
Provides health care instruction/education to patient and family members.
Performs a variety of nursing administrative duties.
Assists attending physicians and aids patients and families as needed in times of stress or crisis.
Common Expectations:
Maintains a safe, comfortable and therapeutic environment for patients/families in accordance with hospital standards.
Demonstrates knowledge of the principles of growth and development over the life span of the assigned patient population. Assesses and interprets patient age specific data and provides appropriate, age specific treatment. Provides direct patient care to assigned patient age group(s).
Demonstrates a commitment to patient, visitor and staff by: complying with all applicable safety regulations; learning the impact of medical errors and methodology that will lead to reduction of errors; reporting actual and potential errors, as well as hazardous conditions; identifying opportunities to standardize processes and "error proof" systems that will lead to increased safety; and participating in safety education programs and root cause analyses as required.
Maintains established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
Enhances professional growth and development through participation in educational programs, current literature, inservice meetings, and workshops.
Ensures an adequate stock of supplies and proper functioning of equipment.
Attends meetings as required.
Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
Required for All Jobs:
Performs other related duties as identified.
WellSpan Health has adopted and implemented a compliance program to support WellSpan's values and standards for professionalism, integrity, and ethics. Expected to support and meet the values and standards of the organization and the performance expectations of the job, the department, and the compliance program.
WellSpan Health has adopted and implemented a privacy program to safeguard the patient information and the business and operational information of the organization. Expected to support and meet the values and standards of the organization to safeguard patient and business/operational information.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.
Physical Demands:
Standing - Frequently
Walking - Frequently
Sitting - Occasionally
Carrying/Lifting - Occasionally (50lbs)
Pushing/Pulling - Occasionally (50lbs)
Kneeling/Crouching - Occasionally
Reaching - Occasionally
Talking - Frequently
Hearing - Frequently
Repetitive Motions - Occasionally
Eye/Hand/Foot Coordination - Occasionally
Working Environment:
Occupational Hazards - Occasionally
Bloodborne Pathogen - Exposure
Qualifications
Minimum Education:
Associates Degree Required
Work Experience:
1 year Relevant experience. Required
Licenses:
Licensed Registered Nurse Upon Hire Required or
Registered Nurse Multi State License Upon Hire Required and
Basic Life Support Upon Hire Required and
Advanced Cardiac Life Support Upon Hire Preferred
Courses and Training:
If assigned to Imaging - radiation protection. Upon Hire Required
Knowledge, Skills, and Abilities:
If assigned to Imaging - IV Therapy, EKG, catheter insertion, radiation protection.
Employment Benefits
Sign-on incentives for new employees
Medical, dental and vision insurance
Life and accidental death insurance
Supplemental life insurance
Retirement savings plan
Paid time off (PTO)
PTO bridging
Short-term disability
Educational assistance
Forgivable loan
Flexible spending
Credit union
Employee recreational activities
Childcare
Complimentary medicine discounts

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