Medical Records Nurse

3 months ago

Chapel Hill 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 University Hospital

Pursue your passion for caring with Duke University Hospital in Durham, North Carolina, which is consistently ranked among the best in the United States and is the number one hospital in North Carolina, according to U.News and World Report for 2023-2024. Duke University Hospital is the largest of Duke Health's three hospitals and features 1048 patient beds, 65 operating rooms, as well as comprehensive diagnostic and therapeutic facilities, including a regional emergency/trauma center, an endo-surgery center, and more.
 
Adult Medicine Stepdown 2300
Registered Nurse (Experienced/New Grad)
ALL SHIFTS AVAILABLE
Plan, provide and document professional nursing care, utilizing the nursing process, in accordance with physician orders and established policies and procedures under the supervision of the team leader or charge nurse.
Delegate tasks and supervise the activities of other licensed and unlicensed care providers.
Assist other healthcare personnel in the delivery of patient care.
Participate in maintaining the environment of care including equipment and material resources. Prioritize work organization and identify resources available to assist in completing components of care in a timely manner.
Participate in own professional development by maintaining required competencies, identifying learning needs and seeking appropriate assistance or educational offerings.
Support the development of other staff and formal learners.
Participate in the identification of clinical or operational performance improvement opportunities and assist in performance improvement activities.
Graduation from an accredited Bachelor's Degree in Nursing (or higher), Associate's Degree in Nursing or Nursing Diploma program is required.
All registered nurses without a Bachelor's degree in Nursing (or higher) will be required to enroll in an appropriate BSN program within two years of their start date and to complete the program within 5 years of their start date.
 
No experience required.
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
Ability 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.
 

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.

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