Medical Records

4 weeks ago

San Antonio TX, United States South Texas Spine & Surgical Hospital Full time

Operating Room Registered Nurse
Under the supervision of the OR Manager or the designated representative and according to organizational structure, the Operating Room Registered Nurse is responsible for providing intra-operative patient care in accordance with sound nursing judgment, regulatory and accreditation standards, and the facility's mission, vision, and values. The position must provide direct and indirect patient care across the age continuum; and utilize the nursing process of assessment, planning, implementation, and evaluation according to policies and procedures of the facility and out patient surgery center.
Administrative responsibilities include internal physician marketing, cost awareness, and adherence to staffing schedule. Supervises other Registered Nurses as requested, and directs ancillary staff in the operating room and central processing. Responsible to assist with administrative tasks related to Risk Management, Infection Control, Performance Improvement, and Clinical Recruitment/Retention. In conjunction with the nursing leadership, the OR Nurse may assist with development and implementation of policies and procedures, which assure that cost effective, safe and high quality of care, is implemented.
Projects a professional demeanor and appearance while maintaining the confidentiality of patients, coworkers, and facility information and adhering to the HIPAA policy. seeks guidance, direction, and assistance when needed. Fosters an attitude of teamwork and willingness to assist others and does not refuse performing other job duties as requested. May also be required to interchange from facility to Hospital Outpatient Department as needed. The patient population served by South Texas Spine & Surgical Hospital is a minimum of 12 years and/or of adult stature to geriatric patients requiring or seeking pain and/or surgical intervention.
May be expected to lift up to 50 pounds or up to 150 pounds with assistance. May be expected to push or pull 150-300 pounds with assistance. Visual and auditory acuity and manual dexterity essential to performing designated duties required. Manual dexterity involving the handling of equipment and instruments or armamentarium is essential to performing assigned duties. May be subjected to unpleasant sights and odors, stressful situations, limited radiation, hazardous chemicals, or infectious diseases where judgment as to precautions needed to be taken is essential. Climate control and ambient temperature variances may be experienced and required by patient care and needs of the surgical team. Personal protective equipment is made available and must be worn.
Graduate of a school of professional nursing with current and valid licensure with Texas State Board of Nursing as a Registered Nurse.
* Minimum of two years of experience required in the Operating Room or other critical care-nursing environment.
* Knowledge of commonly used concepts, practices, and procedures within a particular field.
* Knowledge of state, federal and accrediting body regulations and standards related to healthcare.
* Ability to read, write and communicate effectively in English, with additional languages preferred.
* Must be computer literate with basic fundamental computer skills that are required to perform essential job related duties.
Adheres to staffing schedules, attendance policy, and cooperates with daily assignments as requested.
* As A Registered Nurse, shows appropriate delegation, while directing and supervising ancillary personnel in planning, implementing, monitoring and evaluating patient care in the operating room according to accepted standards. Provides direct patient care in clinical areas and demonstrates clinical competence.
* Participates in orientation of new staff and peer evaluation process, ensures facility morale exemplifies the mission and values of the center.
* Participates in all staff meetings for department and facility for informative and educational purposes.
Demonstrates highly effective communication skills with staff, management, physicians, patients, and family members.
* Keeps customers informed of progress related to clinical operations and provides comfort, information and assistance during the process.
* Models appropriate interaction with physicians, patients and staff to ensure high level of service in all areas of responsibility.
* Reviews daily schedule and prepares cases based upon preference cards and specific patient care needs.
* Communicates intra-operative care to PACU staff upon transfer.
QUALITY
* Initiates physical and psycho/social assessment and pre-operative plan of care, identifies patient and verifies informed consent.
* Actively participates and validates site marking and initiates timeout according to policy and procedures.
* Assures the delivery of quality clinical care through participation in SP benchmarking programs.
* Assures facility clinical policies and procedures are followed.
* Maintains a safe OR environment, adheres to all patient care safety requirements.
* Reviews and participates in performance improvement initiatives.
* Medical record documentation is accurate, legible, and in accordance with federal and accrediting standards.
Participates and assists with implementation of cost saving initiatives for the department.
* Appropriate staffing levels and overtime is below established benchmarks.
* Medical record documentation and implant log should be completed accurately for all cases.
Through competency and customer service, employee will contribute to the growth of the facility.
* Expanding Knowledge in Job Field (Seminars/In-services)
* Employee communicates service line development ideas with facility leadership.
* Employee engages in customer service conversation with physicians as adjunct to facility marketing initiatives.

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