Mills

CASS REGIONAL MEDICAL CENTER•Harrisonville, MO

5d•Onsite

About The Position

To provide safe high-quality patient care while following all standards of care and regulatory requirements. To provide timely and accurate documentation to assist in billing of services and ensure a complete medical record. To provide Patient and family education. To ensure patient satisfaction by providing the highest level of customer service, assisting in identification and implementation of strategic initiatives including using AIDET in accordance with hospital mission, vision and values. Formal Policy-Setting Responsibilities: Formally responsible for making recommendations regarding policies associated with the job's purpose and essential responsibilities. Routine Decision Making: Determine patient/ physician needs and act accordingly. Determine appropriate patient scheduling, while meeting the needs of urgent patients. Assessment and education of patients and appropriate referrals to other disciplines. Triaging of patients and notifying physicians of abnormal findings in a timely manner. Coordinate care with Prior Authorization/scheduling. Formal Supervisory Responsibility: No formal supervisory responsibility. Required Knowledge: Knowledge of medications, possible reactions, disease processes, equipment; nursing process; insurance requirements; standards of care; regulatory requirements, and patient triage. Required Skills and Ability: Organization and Problem-solving skills. Effective and professional interpersonal communication skills. Ability to multi-task and prioritize patient assessment and nursing care. Ability to work independently and as a team. Use of critical thinking skills to identify, analyze and prioritize issues. Assist in identification of solutions in collaboration with others. Unusual Working Conditions: Risk of blood, body fluid contamination, potential exposure to hazardous drugs and chemicals. Age Specific Competencies: Provides care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

Requirements

RN degree
currently licensed in the State of Missouri
BLS required

Nice To Haves

Chemotherapy and Biotherapy Certification preferred

Responsibilities

Ensures required records have been received. Ensure accuracy and completion of the medical record in collaboration with the provider- check medical record for inconsistencies, notify provider and check to ensure the inconsistencies are resolved.
Prepares rooms prior to each visit, sets up appropriate equipment if applicable, cleans room before and after each patient and at the end of the day.
Identifies the patient using the 2 approved patient identifiers prior to all patient care including administration of medication or collection of specimens.
Documents vital signs to include weigh, height, blood pressure, pulse, O2, and temperature at each visit. Documents pain level and other required assessment at each visit including medication and reconciliation.
Documents and reports all critical vital signs and critical test results to the ordering provider per hospital policy and implements further orders per policy. Documents details in the patient record.
Maintains patient care documentation logs as assigned per clinic/provider and regulatory agencies.
Places orders and medications as ordered by provider through Meditech (when able).
Obtains or confirms consents are correct and valid if indicated. Ensure all orders are complete, patient appropriate, timing is accurate, criteria are met and orders have prior authorization.
All medication is administered per policy and documented in chart.
Maintain confidentiality and privacy of information in accordance with HIPAA regulations and organizational policies.
Infusion nursing will perform and document nursing interventions in Meditech, evaluate the information, identify and implement interventions to meet the needs of the patient. Collaboration with the provider and clinical staff.
Utilizes critical thinking skills to carry out provider orders.
Triages patient phone calls, documents in the medical records and notifies provider as appropriate.
Serves as a clinical resource to providers and staff.
Review chart to ensure that continuum of patient is care is met.
Effectively communicate and provide discharge instructions to patient and responsible party at the end of every visit. Schedule patient appointments.
Educates or reinforces education on all procedures and/or medications to patients prior to implementation.
Orders supplies and special-order supplies to maintains appropriate levels of inventory for effective patient cost containment.
Responsible for care (cleaning and storage) of equipment following all manufacturer instructions for use (IFU) for user cleaning and equipment.
Reports all emergent problems to manager. Tags and removes malfunctioning patient care equipment immediately and complete work requisition.
Completes monthly quality checks as assigned. Enters appropriate repair tickets as indicated and follows up to ensure completion.
Assist in orientation and training of new staff.
Keeps clinic clean and clutter free.
Other assignments as indicated.
Appropriately prepares rooms prior to each patient visit, obtaining equipment and instruments.
Confirms consent has been obtained if required prior to the procedure.
Identifies the patient by using the two approved patient identifiers prior to procedure or medications.
Document in the medical record as indicated.
Effectively communicate discharge instructions to patient and responsible party at the time of discharge.
Plans, develops and evaluates self-objectives at a minimum annually.
Routinely looks for opportunities to make improvements in the department.
Works with team and participates in implementing planned changes and activities.
Performs ongoing evaluation of changes, determine needed changes, discuss with stake holders and then implement updated changes to improvement.
Attends department staff meetings.
Other duties as assigned within the scope of practice.