Medical Records Nurse

4 weeks ago


San Antonio, United States CHRISTUS Health Full time

Description Summary: Provides circulating nurse services in the operating room during surgical or pain management procedures and assists the surgical team as needed in any other capacity, according to established procedures. The staffing of the Center is based on a teamwork concept. Employees may be cross-trained in other clinical areas and may be expected to perform duties other than their normal ones as staffing and patient needs change. Responsibilities: Supervises and directs patient care in the individual operating /pain rooms Performs all circulating duties with efficiency and speed Ensure patient's emotional, physical and psychological needs are met Ensures that proper techniques and practices are used according to accepted standards of practice Supervises and assists scrub technician as necessary Ensures care of patient through proper identification, checking of chart, and reporting of changes in condition Performs scrub duties as necessary Assists in control and maintenance of supplies and equipment Assists the anesthesiologist/CRNA as necessary Documents all nursing care delivered in the operating /pain room in the medical record Performs other nursing duties as assigned Maintains established Center/departmental policies and procedures Maintains confidentiality of patient and Center related business Develops and maintains an effective working relationship with patients, families, visitors and other Center employees Documents concisely, precisely and accurately on all records or documents as indicated by policy Participates in Quality Assessment activities as directed for the continuous improvement of patient care and Center business Ability to adequately assess, diagnose, plan and implement nursing interventions and evaluate patient condition Compliance with the attendance policy Compliance with continuing and mandatory education programs Practices nursing within the scope of the Nurse Practice Act and accepts responsibility and accountability for own actions Possesses appropriate communication skills to practice collaborative nursing Ability to respond quickly, physically and mentally when priorities and /or the patient's condition changes Qualifications: Graduate of an accredited school of professional nursing Licensed to practice in the state of Texas CNOR preferred Operating room experience (minimum 1 year) Current BLS, ACLS required Work Type: PRN


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