Medical Records Nurse

3 weeks ago

York PA, United States WellSpan Health Full time

*General Summary*
Provides professional nursing care at the beginner practitioner level in accordance with the principles of patient and family-centered care based on the nursing process and according to the clinical standards of the hospital. Acts as a primary nurse for patients on the unit. Coordinates care planning with other disciplines. May require specialized skills depending on unit assignment.
*Employment Benefits*
* Comprehensive health benefits
* Flexible spending and health savings accounts
* Retirement savings plan
* Paid time off (PTO)
* Short-term disability
* Caregiver support
* Education assistance
* Financial education and support, including DailyPay
*Duties and Responsibilities*
*Essential Functions:*
* Provides and coordinates direct care in accordance with the principles of patient and family-centered care based on the nursing process and according to the clinical standards of the hospital. Acts as a primary nurse for patients on the unit. Synthesizes patient data to develop outcome-driven plans.
* Safely and independently administers prescribed treatments, medications, and nursing interventions based on assessment and plan of care.
* Appropriately organizes and prioritizes time based on patient condition and expected workload. Identifies changes in patients- status and acts accordingly. Knows and can activate resources to achieve outcomes for patients.
* Seeks mentoring and coaching from the CN II & III.
* Identifies and communicates individualized patient needs for safe handoffs during transitions of care. Collaborates with patient/family in care planning with all disciplines.
* Appropriately and correctly documents the patient response to interventions and progress toward outcomes. Identifies and documents variances. Appropriately utilizes flow sheets, progress notes, and/or electronic medical record for documentation. Is able to identify system and unit-based nursing sensitive indicators; i.e. falls, pressure ulcers.
* Identifies own areas of professional growth and development in performance improvement efforts. Recognizes the value of evidence based research as it applies to best practice.
* Promotes a professional practice environment that supports patient safety and quality through interdisciplinary collaboration, Shared Decision Making activities including peer review. Integrate Shared Decision Making by unit committee membership or by supporting and helping fellow co-workers attend committee meetings and/or work on SDM projects. Serves as positive role model.
* Delegates aspects of care to other nursing personnel in order to meet patient needs. Helps assistive personnel organize and set priorities for work. Monitors completion of tasks that are assigned or delegated to the patient care team.
* Promotes collaboration and cooperation among physicians, nursing staff, and other members of the interdisciplinary team. Contributes to effective communications among all team members. Begins to display conflict resolution and negotiation skills to maximize team performance.
* Variation of duties may result based on the assigned customer care unit(s). This may include differences in the specific clinical skills required of the RN. Unit based skill lists outline expectations beyond the house wide RN requirements. SYS-NURS-L Nursing Education Requirements Policy outlines current certification(s) required for specific areas of nursing practice and is considered to be part of the-job description.
*Common Expectations:*
* 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 Adheres to established policies and procedures, objectives, quality assessment, safety, environmental and infection control standards.
* Enhances professional growth and development through advanced/continuing education to maintain up-to-date knowledge, skills, and competencies.
* 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:*
* Diploma Program Required or
* Associates Degree Required
* Bachelors Degree Nursing (BSN) Preferred
*Work Experience:*
* No 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
Job Type: Full-time
Medical specialties:
* Cardiology
* Emergency Medicine
* Medical-Surgical
Standard shift:
* Day shift
* Night shift
Ability to Relocate:
* York, PA: Relocate before starting work (Required)
Work Location: In person

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