Overnight Rn Data Abstraction Jobs in Rochester, NY

Under the direction of the RN Nursing Supervisor, Unit Manager, ADON or ADON – Unit, or Center Nurse Executive (Nurse Leader), the Registered Nurse (RN) delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction. He/she operates within the scope of practice defined by the State Nurse Practice Act and delegates aspects of patient care to LPNs and CNAs consistent with their scope of practice. The RN manages patient care by performing nursing assessments and collaborating with the nursing team and other disciplines, patients and families to develop effective plans of care.

Responsibilities/Accountabilities:

• Assessment:
• Collects, validates, synthesizes, and records objective and subjective data.
• Prioritizes data collection based on patient needs.
• Analyzes all data.
• Identifies actual or potential problems or needs based on data analysis.
• Care Planning:
• Establishes realistic and measurable short and long term goals for the identified health problems and needs.
• Develops individualized interventions to achieve goals.
• Determines timelines within the care plan.
• Conducts a systematic and ongoing evaluation of patient outcomes.
• Reviews and revises plan of care as indicated.
• Implementing Care:
• Performs nursing functions and provides care within scope of practice.
• Coordinates and delegates care as appropriate.
• Verifies that medical orders are accurately transcribed.
• Administers medications and performs treatments per physician orders.
• Communicates and documents interventions and patient response.
• Managing patient care:
• Delegates care responsibilities to staff considering: complexity of care, competency of staff, center policies, and state's practice act.
• Supervises staff to ensure that delegated tasks and interventions are implemented appropriately and per policy.
• Evaluates and adjusts the plan of care to achieve patient goals and minimize re-hospitalizations.
• Actively participates in Utilization Management or Interdisciplinary Care Management Meeting to facilitate appropriate discharge planning: communicates team's recommendations for discharge to the attending physician, patient and family. Prepares patient/family for discharge including patient and family education.
• Communicates patient information with assigned staff during and between shifts.
• Participates in shift-to-shift communication between incoming and outgoing nursing staff.
• Uses Point Click Care (PCC) according to the Business Processes.
• Performs drug count when beginning and ending shift and whenever necessary.
• Collaborates with physicians in rounds and examination of patients, as needed.
• Collaborates and coordinates with other departments to provide timely effective care consistent with individual's needs, choices and preferences.
• Contributes to an environment that is respectful, team-oriented, and responsive to the concerns of staff, patients and families.
• Enhances nursing practice by attending all mandated in-service programs and other GHC and outside professional education programs.
• Assists with the orientation of newly hired nursing staff.
• Promotes a culture of safety to ensure a healthy practice and living environment.
• Maintains confidentiality and protects sensitive Protected Health Information (PHI) at all times.
• Stays and works beyond scheduled shift if needed to meet state staffing requirements and/or needs of patients.
• Performs other duties as requested.

Compliance:

• Complies with applicable legal requirements, standards, policies and procedures including but not limited to those within the Compliance and Ethics Program, Standard/Code of Conduct, Federal False Claims Act and HIPAA.
• Participates in required orientation and training programs.
• Promptly reports concerns and suspected incidences of non-compliance to supervisor, Compliance Liaison or to the Compliance Officer via the Integrity Hotline.
• Cooperates with monitoring and audit functions and investigations.
• Participates, as requested, in quality assurance and process improvement activities.

Specific Educational/Vocational Requirements:

• Graduate of an approved school of nursing is required.
• Must be currently licensed by the State Board of Nursing.

Job Skills:

• Current physical assessment skills and comprehensive knowledge of nursing principles required, including the ability to recognize and identify symptoms and manage emergency situations.
• Knowledge of medications, their proper dosage, and expected results.
• Ability to coordinate, delegate and supervise nursing functions, problem solve and make decisions as necessary.
• Ability to create a patient-centered environment.
• Ability of communicate in English both orally and in writing.
• Basic knowledge of computer use.