Medical Records

4 weeks ago

San Antonio, United States Surgery Partners Full time

South Texas Spine & Surgical Hospital is dedicated in exceeding expectations through building relationships with patients, physicians, staff and community. Our mission is to make our patients feel like family by going over and beyond and providing exceptional care. We encourage our hospital to empower others, build one another up and continue to grow We are currently seeking like-minded employees to provide exceptional and quality care to our patients. We want you to help be the face of our hospital as we are proud to provide extraordinary quality care.

Under the supervision of the ER/Inpatient Manager, the ER/Inpatient Registered Nurse is responsible for providing direct and indirect patient care in the Medical-Surgical setting. Evaluates, plans, implements, and documents nursing care for an assigned patient population. Promotes patient's' independence by establishing patient care goals and teaching patient and family to understand condition, medications, and self-care skills. Emergency Room duties, when in a Charge role, consist of directing nursing service activities in the Emergency Room setting. In addition, provides professional nursing care of assigned patients in the emergency room setting. Triages each patient and determines priority of care based on physical, psychological and social needs as well as factors influencing patient flow through the emergency care system. Performs focused assessment of chief complaint on each patient in a timely manner according to established triage guidelines. Administrative responsibilities include cost awareness, and adherence to staffing schedule. and directs ancillary staff in the Emergency Room and Medical Surgical area. In conjunction with nursing leadership, the ER/Inpatient Registered 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. 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. 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.
* 2 years of nursing experience required in the Medical/Surgical area.
* 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 ER/Medical/Surgical clinical areas according to accepted standards. Provides direct patient care in the assigned clinical areas and demonstrates clinical competence.
* Participates in orientation of new staff, ensures facility morale exemplifies the mission and values of the facility.
* 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 patient care areas based upon types of procedures and specific patient care needs.
* Communicates changes in status as necessary to physicians, family members, and other staff.

QUALITY

* Complete and document physician orders, obtain necessary diagnostic test results and notifies appropriate physicians and staff regarding variances and/or concerns.
* Completes and documents discharge phone calls and reports problems and/or concerns.
* Completes the Nursing Notes and assures all patients have met the discharge criteria prior to discharge; Assures the delivery of quality clinical care through participation in SP benchmarking programs.
* Assures facility clinical policies and procedures are followed.
* Maintains a safe clinical 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 in quality improvement activities.

Participates and assists with implementation of cost saving initiatives for the department.
* Appropriate staffing levels and overtime is below established benchmarks.
* Medical record documentation should be completed accurately for all cases.

Through competency and customer service, employee will contribute to the growth of the facility.
* Employee communicates service line development ideas with facility leadership.
* Employee engages in customer service conversations with physicians as adjunct to facility marketing initiatives.

This position offers premium pay, shift differentials (if applicable), a full suite of medical benefits, 401K, tuition reimbursement, and an opportunity to grow with an outstanding organization

This position offers premium pay, shift differentials (if applicable), a full suite of medical benefits, 401K, tuition reimbursement, and an opportunity to grow with an outstanding organization.

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