medical scribe jobs

Registered Nurse STEPDOWN 7P-7A

JOB SUMMARY Responsible for the delivery of patient care through the nursing process of assessing, diagnosing, planning, implementing and evaluating. Responsible for the directing and coordinating all nursing care for medical/surgical patients based on established nursing practice standards. Collaborates with other professional disciplines to ensure effective and efficient patient care delivery and the achievement of desired patient outcomes. Supports the organizational vision and mission. Utilizes knowledge of patient’s age and cultural diversity into the provision of patient care. JOB REQUIREMENTS Minimum Education Holds an active Registered Nurse license, and is eligible to practice in the state of Kentucky. Current BLS certification. Minimum Work Experience Ability to utilize the nursing process in the provision of nursing care including but not limited to administering medications and treatments, interpreting diagnostic tests, formulating a plan of care, collaborating with other health care providers, and providing education to patients and/or significant others. FUNCTIONAL DEMANDS Physical Requirements Sitting - 1-15% Walking - Greater than 32% Standing - Greater than 32% Bending/Squatting - 16-31% Climbing/Kneeling - 1-15% Twisting - 1-15% OSHA Category High Potential for Direct Body Fluid Exposure Visual and Hearing Requirements Must be able to see with corrective eye wear. Color vision ability required. Must be able to hear clearly with assistance. Other Physical/Environmental Demands Lifting - 0-50lbs, 50lbs or more with assistance Carrying - 0-50lbs, 50lbs or more with assistance Pulling - up to 200lbs Pushing - up to 200lbs LEADERSHIP CAPABILITIES Supports the hospital Mission, Service and Values. ESSENTIAL FUNCTIONS Essential Functions - Assessment • Performs complete & holistic health assessments on admission using a systematic, ongoing approach to collecting data about patients & documents findings. • Assessment data includes physiological, psychological, sociocultural, spiritual, economic, and life-style factors. • Performs focus assessments as needed, based on a specific problem identified during a previous assessment or reported by another staff or family member. • Performs daily assessments comparing current status to baseline. Detection of changes in functioning, mental status, wound healing, or other health concerns are reported to the appropriate person and documented accurately. • Demonstrates good communication and observation skills in completing assessments. • Demonstrates good physical examination skills in completing patient assessments. Essential Functions - Diagnosis • Analyzes assessment data using sound clinical judgment about the patient's response to actual or potential health conditions or needs in determining patient problems and needs. • Appropriately prioritizes patient needs based on assessment data. • Formulates and documents measurable, realistic, patient focused short and long range goals based on analysis of data. Essential Functions - Implementation • Communicates and collaborates with other healthcare providers as needed to ensure continuity of care. • Assigns tasks or delegates care based on the needs of the patient, taking into consideration the knowledge and skill of the patient care provider. • Serves as a team leader for a group of nursing personnel. • Operates and/or supervises the safe operation of patient care equipment. • Documentation is detailed, clearly stated, objective, and accurate. • Documentation is free of unapproved abbreviations and uses proper spelling and grammar. • Written and verbal orders are transcribed accurately and promptly. • Demonstrates understanding of confidentiality of patient information by using complete discretion when discussing information. • Provides clear concise and accurate information when giving report to other healthcare workers or facilities. • Documents interventions completely, appropriately, and in a timely manner. • Implements and documents patient and family teaching as part of the plan of care. • Documents complete skin assessments and prevention interventions as required by policy. • Patient pain is assessed at intervals described in policy with interventions implemented promptly if needed. • Assists with direct hands on patient care as needed. Essential Functions - Evaluation • Makes rounds on patients to determine if plan of care is appropriate or if it needs to be altered. • Alters plan of care to meet individual needs of patient. • Counsels and initiates corrective action for nursing employees as necessary and promptly informs the appropriate supervisor. • Contributes to the professional development of peers, colleagues, and other healthcare providers by sharing knowledge and skills, and by providing constructive feedback regarding practice issues. Essential Functions - Age Specific • Demonstrates knowledge of patient population served including development norms and addresses • abnormal findings. • Demonstrates knowledge of appropriate assessments and planning of care for patient population served. • Demonstrates competency and knowledge of appropriate equipment of patient population served. • Demonstrates appropriate airway management and suctioning technique for patient population served. • Demonstrates appropriate awareness for suspected abuse/neglect for patient population served and takes measures to report them according to protocol. • Identifies and plans for appropriate safety precautions to be taken to prevent injury in the patient population served. • Demonstrates competency and knowledge in the proper technique for the administration of medication for the patient population served. • Demonstrates knowledge of appropriate technique to obtain vital signs and is able to interpret norms for the patient population served. • Demonstrated knowledge of location and use of emergency equipment and drugs for the patient population served. • Provides education to patient/family based on identified learning needs of the patient population served. NONESSENTIAL FUNCTIONS • Floats to other areas as assigned, responds to floating requests with a positive attitude. • Participates in 75% of staff meetings as evidenced by attendance records. • Completes competency assignments as evidenced by in-service record. • Maintains current status in CPR. • Annual Employee health requirements are kept up to date. • Performs other duties as assigned with a positive attitude.