Part Time Rn Medical Record Review Jobs in Wisconsin

Registered Nurse

Department: ASC

Location: ASC

Reports To: ASC RN Manager

Employment Status: Part Time

FLSA Status: Non-Exempt

About the Employer

Founded in November of 2020, Pain Physicians of Wisconsin is a group of Physicians, Nurse Practitioners, Physician Assistants, and a great group of support staff serving the southeast region of Wisconsin. The goal of our pain treatment team is to help our patients live their healthiest lives possible by easing pain symptoms and restoring function and movement. Learn more about PPWhealth by visiting our website at www.ppwhealth.com.

Position Summary

The purpose of this position is to perform individualized, goal directed nursing care through use of the nursing process and the principles of team nursing in accordance with Pain Physicians of Wisconsin, S.C. (PPW) policies and procedures. This position will also assess patient health problems and needs, develop, and implement care plans, and maintain medical records and administer nursing care to adult patients in the Perioperative areas of the Ambulatory Surgery Center.

1. Provides skilled nursing care under the direction of the RN Charge nurse or RN Manager
2. Consults and coordinates with health care team members to assess, plan, implement and evaluate patient care plans, using specialized clinical and surgical equipment.
3. Observes and documents patients' clinical and educational needs to complete the nursing assessment and provide care.
4. Actively performs surveillance for Infection Control risks in the ASC, monitors hand hygiene compliance.
5. Actively participates in Universal Protocol/ surgical Time out process by leading actively listening and responding regarding the confirmation of correct patient, using two patient identifiers, correct procedure, side/site, etc.
6. Maintains a focus on patient safety, protects the privacy and preserves the dignity of the patient.
7. Effectively communicates with all Physicians and staff members.
8. Accurately monitors, records and reports on patients' clinical information and vital signs.
9. Educates individuals, families, and other groups on topics such as health concerns, pre-operative, intra-operative and post-operative care needs.
10. Assists pre/post procedure by preparing patient for procedure; correctly identifying patient, procedure to be performed, and procedure site. Updates and confirms medication and allergy profiles, completes appropriate clinical lab work (glucose reading, INR, pregnancy test) completes and documents vital signs, pain status, and health care concerns of patient. Performs pre- and post-operative teaching. Reviews consent form and orders for accuracy. Uses the five rights when administering medication. Documents modified Aldrete and discharge scores. Assists in discharge of patient with appropriate paperwork, with excellent communication and teaching skills.
11. Performs chart review on daily basis to ensure completeness and accuracy of documentation in the medical record.
12. Participates in team peer review process, reviewing nursing documentation by other clinical staff and providing feedback according to organizational process.
13. Helps support corporate Quality Assessment and Performance Improvement initiatives as a member of the ASC Team.
14. In the OR: Supervises and directs patient care in a single operating room. Identifies the patient and correct surgical intervention according to policy/procedure and communicates such information to all members of the surgical team. Explains intraoperative phase of routine procedures and care to the patient. Administers sedation under the supervision of the physician by following verbal orders, as well as using nursing assessment and critical thinking skills. Can perform role in a safe, organized, and efficient manner. Documents accurately the intraoperative phase, as well as medication documentation in EHR and controlled substance logs. Applies and monitors principles of aseptic technique throughout intra-operative period. Assists provider by having all necessary equipment available and ready. Efficiently "turns over" rooms between patients following proper cleaning technique. Communicates all breaches of aseptic technique immediately to the physician and circulating nurse.
15. C-Arm: Completes and maintains appropriate radiation training and competencies. Assists in monitoring radiation methods that expose all staff to the least amount of exposure. Assists in maintaining radiological equipment and proper badge usage and storage. Actively participates in the patient timeouts. Documents fluoroscopy usage and correct storage and printing of images as determined by site and C-ann.
16. Triage: Effectively communicates with physician regarding patient health care needs. Documents accurately in EHR, creates encounters as needed, properly updates, and utilizes medication module. Tasks and communicates with providers regarding assessment of patient needs.
17. Preceptor: Effectively communicates with other employees by teaching and directing them as to the responsibilities of the job; communicates with manager regarding progress of trainee. Monitors trainee and does not leave them unassisted until they are able to perform their role independently. Actively and enthusiastically participates in the orientation process striving for independence and success of the trainee. Assists trainee in the completion of all required competencies, skill checklists.
18. All other duties as assigned.

Qualifications

1. Successful completion of an accredited Registered Nursing program evidenced by holding current and unrestricted RN license.

1. At least five years of related experience preferred.

1. Strong organizational, judgment, communication, and analytical skills; sometimes under pressure.

1. Ability to multi-task and perform multiple priorities.

1. Professional, pleasant, and caring behavior toward patients, peers, providers, organizational leadership, and visitors.

1. Able to use, demonstrate and model critical thinking skills.

1. Ability to promote favorable organization image with patients, physicians, insurance companies and general public.
2. Ability to independently make decisions and solve problems; ability to apply general rules to specific problems to produce answers that make sense.

1. Evidence of leadership qualities in the team. Frequently contributing to the improvement of the department and participate in committee participation, task force, etc.

I 0. The ability to contribute to a team environment and to provide excellent customer service.

11. Working knowledge of Microsoft Office.

Licenses & Certifications

1. Current and unrestricted RN license in the State of Wisconsin.

1. BLS certified or obtain certification within three months of hire. ACLS certified or obtain certification within the first year of hire.

Pre-Employment Testing

This position requires the following pre-employment testing:

Criminal & Caregiver Background Check, renewed every four years

Professional Reference Check

TB & Rubella Screen

Drug Screen

Please note that this job description is intended to describe the general nature and level of work being performed by the employee(s) assigned to this job. The content contained therein is not intended to represent an exhaustive list of all duties, responsibilities, and activities required. Duties, responsibilities and activities may change at any time, with or without notice, and additional work may be assigned as appropriate.

We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of non-job related disability, or any other legally protected status.