Position Status:

Full time

Shift:

First Shift (Days - Less than 12 hours per shift) (United States of America)

Hours per week:

40

Job Information
Exemption Status: Non-Exempt

A Brief Overview
Provides professional nursing care, under supervision, various patients. This position spends a high percentage of time performing medical transcription duties as a "real time" Documentation Assistant for a specific physician. Time is spent routing and processing documentation and delivering reports to physicians for review in a timely manner. Core responsibility is to capture accurate and detailed documentation of the patient encounter in a real time manner. Member of the patient care team who uses acquired, clerical skills to assist in maintaining efficient workflow to ensure safe, quality care with a patient centered approach focusing on continuity of patient care and satisfaction. This role is designed to support the Physician through the management and completion of the admission, progress notes and discharge summary within the scope of their practice. Making independent clinical decisions is outside of the scope for this position, refer clinical questions to the provider or nurse.

Skills and Abilities

• Skill in using various types of equipment for examination and treatment procedures. Skilled in taking vital signs. (Required proficiency)

• Skill in administering a variety of treatments and medications as directed. (Required proficiency)

• Knowledge of common safety hazards and precautions to establish a safe work environment. Knowledge of the principles and skills needed for practical nursing to provide patient care and treatment. (Required proficiency)

• Knowledge of examination, diagnostic, and treatment room procedures. (Required proficiency)

• Knowledge of medications and their effects on patients. (Preferred proficiency)

Licenses and Certifications

• Licensed Practical Nurse - KSBN Required

What you will do

• Collects pertinent data and information relative to the patient, situation, or setting. Collaborates with care team to identify expected outcomes and develop a plan individualized to the patient or situation.

• Implements identified plan through coordination of care and employs strategies to promote health and wellness. Promote infection prevention through use of standard precautions, proper procedure in dressing changes, wound care, hand hygiene and cleanliness of the patient rooms/department.

• Enters information in EHR as directed by provider. Respond to various EHR messages as directed by the provider. Ensure that all orders entered are read back and confirmed to provider and entered as Pended. Assist the provider in navigating the EHR. Relay all advisories or alerts that appear while scribing to obtain guidance from Provider on proper response.

• Efficiently documents information using the appropriate forms and/or electronic applications. Evaluates the patient’s progress towards achieving outcomes and provides information to the physician as requested.

• Responsible for the documentation of the patient’s progress notes, and discharge summary under the direction and supervision of the physician. Documents in patient and department records in a timely, accurate and concise manner according to department standards.

• All documentation assistant entries must contain an entry made by the provider that affirms the providers presence during the time the encounter was recorded. Verification that provider reviewed the information. Verification of the accuracy of the information. Provider authentication including date and time Individual is required to review and agree to abide by the Scribe/Team Documentation Assistant Policy.

• Delivers professional nursing care guided by Jean Watson’s Theory of Human Caring illustrated by creating caring relationships, taking time to have uninterrupted moments with patients and displaying unconditional acceptance and respect.

• Promotes a mutually respectful environment that encourages the exchange of ideas and supports the effectiveness of professional relationships and integrates ethics in all aspects of practice.

• Demonstrates advocacy in all roles and settings.

• Practices Diversity, Equity and Inclusion principles in their daily work by respecting others’ uniqueness, perspectives, backgrounds or beliefs.

• Communicates effectively in all areas of professional practice.

• Mentors nurses new to their role for the purpose of ensuring successful enculturation, orientation, competence, and emotional support. Supports students to enhance their knowledge, skills, and abilities.

• Commits to lifelong learning through critical thinking, self-reflection, and inquiry for personal growth and development.

• Demonstrates willingness to participate and lead nursing practice in process evolution the scope of the Stormont Vail Health professional practice model.

• Utilizes appropriate resources to plan, provide, and sustain evidence-based nursing services that are safe, effective, and financially responsible, and used judiciously.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health

• Performs other duties as assigned

Patient Facing Options

• Position is Patient Facing

Remote Work Guidelines

• Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.

• Stable access to electricity and a minimum of 25mb upload and internet speed.

• Dedicate full attention to the job duties and communication with others during working hours.

• Adhere to break and attendance schedules agreed upon with supervisor.

• Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

• Hybrid

Scope

• No Supervisory Responsibility

• No Budget Responsibility

Physical Demands

• Balancing: Occasionally 1-3 Hours

• Carrying: Occasionally 1-3 Hours

• Climbing (Stairs): Rarely less than 1 hour

• Crawling: Rarely less than 1 hour

• Crouching: Rarely less than 1 hour

• Eye/Hand/Foot Coordination: Frequently 3-5 Hours

• Feeling: Frequently 3-5 Hours

• Grasping (Fine Motor): Frequently 3-5 Hours

• Grasping (Gross Hand): Occasionally 1-3 Hours

• Handling: Occasionally 1-3 Hours

• Hearing: Frequently 3-5 Hours

• Kneeling: Rarely less than 1 hour

• Lifting: Occasionally 1-3 Hours up to 50 lbs

• Operate Foot Controls: Rarely less than 1 hour

• Pulling: Occasionally 1-3 Hours up to 50 lbs

• Pushing: Occasionally 1-3 Hours up to 50 lbs

• Reaching (Forward): Occasionally 1-3 Hours up to 50 lbs

• Reaching (Overhead): Occasionally 1-3 Hours up to 50 lbs

• Repetitive Motions: Frequently 3-5 Hours

• Sitting: Frequently 3-5 Hours

• Standing: Frequently 3-5 Hours

• Stooping: Rarely less than 1 hour

• Talking: Frequently 3-5 Hours

• Walking: Frequently 3-5 Hours

Working Conditions

• Combative Patients: Rarely less than 1 hour

• Infectious Diseases: Rarely less than 1 hour

• Needle Stick: Rarely less than 1 hour

• Noise/Sounds: Rarely less than 1 hour

• Risk of Exposure to Blood and Body Fluids: Rarely less than 1 hour

Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.

Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.