Medical Records

1 month 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.
WellSpan Health’s vision is to reimagine healthcare through the delivery of comprehensive, equitable health and wellness solutions throughout our continuum of care. As an integrated delivery system focused on leading in value-based care, we encompass more than 2,300 employed providers, 250 locations, nine award-winning hospitals, home care and a behavioral health organization serving central Pennsylvania and northern Maryland. Our high-performing Medicare Accountable Care Organization (ACO) is the region’s largest and one of the best in the nation. With a team 23,000 strong, WellSpan experts provide a range of services, from wellness and employer services solutions to advanced care for complex medical and behavioral conditions. Our clinically integrated network of 3,000 aligned physicians and advanced practice providers is dedicated to providing the highest quality and safety, inspiring our patients and communities to be their healthiest.
WellSpan Medical Group
The WellSpan Medical Group is comprised of almost 5,000 employees and growing fast We have medical practices that represent 51 specialty areas of medicine across 77 locations throughout Central Pennsylvania and Northern Maryland. Wherever your patient care interests fall - whether it’s caring for babies, to end of life care, or anywhere in between to include urgent care - join our amazing team and learn for yourself why WellSpan was just recognized in the Forbes’ list of the 100 best employers in Pennsylvania, with a ranking of No. 24
Working together, our goal is to improve lives through exceptional care for all, lifelong wellness and healthy communities. Our culture is one of respect, diversity and inclusion.
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.


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