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Medical Records Nurse

5 months ago

Peoria IL, United States CARLE Full time

As a member of the interdisciplinary team, contributes professional nursing knowledge and skills in the provision and management of care to patients through the application of the nursing process
Promotes the use of evidence based practice through the nursing process, protocols and procedures.* Develops an individualized plan of care using a collaborative approach with the patient/family and health care team.* Uses appropriate interventions identified in the plan of care to achieve expected patient outcomes.* Systematically evaluates and documents patient's progress toward expected outcomes/goals on an ongoing basis throughout the shift.* Modifies plan of care based on evaluation and as needed based on changes in patient condition.* Demonstrates technical knowledge of equipment and troubleshoots when problems arise.* Acquires and maintains current knowledge and skills in evidence based nursing practice.* Demonstrates skills to promote patient and staff safety through appropriate use of lift equipment (as applicable).* Possesses knowledge and skills necessary to obtain adequate lab specimens for testing.* Performs patient bedside lab testing and associated quality control in compliance with medical provider's orders and hospital lab procedures/policies
WORK ENVIRONMENT & CULTURE FOCUS: Coordinates the interdisciplinary care of the patient through collaboration with team members and utilizes additional resources when necessary.* Collaborates with the health care team in the organization of tasks and activities for the patient's care from admission to discharge according to the plan of care and to meet identified expected outcomes.* Provides goal-focused shift report.* Utilizes communication and teamwork strategies aimed at promoting high team performance and achieving optimal patient outcomes and unit productivity.* Takes cultural, age-specific, gender, and developmental factors into consideration when teaching patients about procedures, illness, hospital experience, etc.* Ensures patient safety in the hospital environment by following policy/procedures and adhering to National Patient Safety Goals.* Consults appropriate resources within the hospital to provide specialized education.*