TCHP REGISTERED NURSE
About The Position
Interviews patients to determine medical problem/condition and documents in chart (EMR) for physician, when necessary obtains and records patient’s vital signs including weight and assists physician with patient examination as needed and explains procedures and treatments to patient to gain cooperation, understanding and allay apprehension, maintains awareness of comfort and safety needs, manages lipids, protimes and phone triage of patient concerns. Follows up on physician orders and lab requests, obtains direction from physician as needed and informs patient of test results and any further treatment prescribed; provides explanation and education to patient; documents services performed in EMR for billing purposes, observes patient, records significant conditions and reactions, notifies supervisor or physician of patient’s condition and reaction to drugs, treatment, and significant incidents, and assists physician in clinical care of patient. Documents nursing history in EMR and physical assessment for assigned patients and initiates a patient education plan according to the individualized needs of the patient, as prescribed by the physician. Abstracts patient records via the EMR. May sort or do chart prep on occasion but not as a routine part of the position. Uses other EMR functions such as tasking, messaging, and disease management. Uses Centricity and other software as appropriate to support nursing functions. Responds to emergency situations based upon nursing standards, policies, procedures, and protocol. Maintains crash cart and defibrillator. All other duties as assigned.
Requirements
- Registered Nurse (RN) license
- Experience with Electronic Medical Records (EMR)
- Experience with Centricity software
- Ability to manage lipids and protimes
- Proficiency in phone triage
- Knowledge of nursing standards, policies, procedures, and protocol for emergency situations
- Ability to maintain crash cart and defibrillator
Nice To Haves
- Experience with chart prep
- Experience with EMR tasking, messaging, and disease management functions
Responsibilities
- Interview patients to determine medical problem/condition and document in chart (EMR).
- Obtain and record patient’s vital signs including weight.
- Assist physician with patient examination.
- Explain procedures and treatments to patients.
- Manage lipids, protimes, and phone triage of patient concerns.
- Follow up on physician orders and lab requests.
- Inform patient of test results and any further treatment prescribed.
- Provide explanation and education to patients.
- Document services performed in EMR for billing purposes.
- Observe patient, record significant conditions and reactions, and notify supervisor or physician of patient’s condition and reaction to drugs, treatment, and significant incidents.
- Assist physician in clinical care of patient.
- Document nursing history in EMR and physical assessment for assigned patients.
- Initiate a patient education plan according to the individualized needs of the patient.
- Abstract patient records via the EMR.
- Use EMR functions such as tasking, messaging, and disease management.
- Use Centricity and other software as appropriate to support nursing functions.
- Respond to emergency situations based upon nursing standards, policies, procedures, and protocol.
- Maintain crash cart and defibrillator.
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What This Job Offers
Career Level
Mid Level
Education Level
No Education Listed
