RN/Registered Nurse Pre-Post Op: Out-Patient Surgery Azura

PURPOSE AND SCOPE:

Supports the Organization mission, vision, core values and customer service philosophy.
Adheres to the Organization Compliance Program, including following all regulatory and Organization policy requirements.

Provides direct nursing care pre, during and post procedure, under the direction of the Facility Manager, Director of Nursing and/or Charge Registered Nurse, utilizing standard nursing techniques to assist the physician in optimum patient outcomes following facility policies and procedures.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

QUALITY:

• Responsible for supporting and driving organization quality standards through meeting regulatory and accrediting body requirements and the practice of Continuous Quality Improvement (CQI), including use of CQI tools.
  
• Assists with implementation of organization quality goals and facility specific action plans in order to achieve organization quality standards.
  
• Accountable for outstanding quality of patient care, as defined by the organization quality goals, to ensure that organization policies and procedures are followed.
  
• Responsible for addressing and acting on adverse events and action thresholds in collaboration with facility management.
  
• Maintains integrity of medical records and other organization administrative and operational records.
  
• Complies with all data collection and auditing activities.
  
• Maintains facility environmental integrity and safety.
  

PATIENT:

• Obtains necessary medical history, discusses procedure and answers questions, and performs nursing assessment on the day of the procedure.
  
• Provides education to patients and patient's family regarding post procedure care of vascular access.
  
• Monitors patient condition before, during and after the procedure, especially patients having moderate sedation and contrast media injections for possible complications or reactions.
  
• Acts as a resource for the patient to address patient concerns and questions.
  
• Identifies and communicates patient related issues to facility management, as needed.
  
• Completes documentation of patient information from admission to discharge in an accurate manner.
  
• Confirm written orders, consents and lab work are completed and documented in accordance with facility policies.
  This includes appropriate preparation of lab requisitions; delivery to appropriate labs; reporting and forwarding of lab results to appropriate physician.
  
• Maintains competency with all emergency operational procedures, and initiates CPR and emergency measures, as needed.
  
• Administers medications and IV moderate sedation to patients as directed per physician's orders, and in compliance with organization, company, federal, state and local regulations.
  
• Acts as scrub technologist to assist the physician during procedure as needed, maintaining a sterile technique.
  
• Assists with patient workflow by transporting patients as needed.
  
• Performs point - of - care laboratory testing as directed per physician's orders and in compliance with organization, company, federal, state and local regulations.
  
• Performs IV insertion as per physician orders.
  
• Performs additional tasks as designated by Physician, practicing in compliance with state regulations.
  

PHYSICIANS:

• Provides regular and effective communication with physicians on an as needed basis.
  
• Attends and participates in CQI meetings with physicians, reporting on assigned topics.
  
• May assist facility management in working with the physicians and staff to verify all necessary instruments and equipment.
  
• Assists the physician in completing and reporting state required adverse event reports and reporting internally as per organization/FMC policy and procedure.
  

MAINTENANCE/TECHNICAL:

• Operates appropriate facility equipment and technology, including but not limited to, patient monitors, defibrillators, medical recording devices, sterilizers and computers in a safe and efficient manner.
  
• Inspects operation of all facility equipment and reports malfunctions, and maintenance needs to ensure the safe and effective operation of all vascular access equipment.
  
• Inspects operation of all facility operating systems, including temperature checks in appropriate areas and physical structure of the facility and reports any issues to the Facility Manager.
  
• Ensures a clean, safe and sanitary environment in the vascular access facility at all times.
  
• Ensures all blood spills are immediately addressed according to the organization/FMCNA Bloodborne Pathogen Control Policies.
  

ADMINISTRATIVE:

• Assists with efficient utilization of medication, laboratory, inventory, supplies and equipment to achieve supply cost goals following all guidelines established in the organization formularies.
  
• May assist in the development and revision of any applicable policies and procedures related to the facility to ensure continuous process improvement.
  
• Assists with Continuous Quality Improvement (CQI) activities including monthly reports and attending meetings as required.
  
• Assists with maintaining medication supply, including inventory control, checking for expired medications, and ensuring appropriate recording of controlled substances as required by law.
  
• Completes usage logs for all medications with appropriate documentation, as well as, records of drug disposal in accordance with local, state, and federal law.
  
• Assists with maintaining facility supply inventory, including ordering and restocking of supplies as needed.
  
• Examines emergency equipment and supplies, including stocking of the crash cart on a regular basis.
  
• Completes medical records in an accurate manner in compliance with organization policies and procedures prior to discharge of the patient.
  Perform chart audits on a regular basis.
  
• May participate in facility regulatory and accreditation surveys and action plans to address any deficiencies.
  
• Completes state required records for all implanted devices in an accurate and timely manner and in accordance with organization/FMS records management guidelines.
  
• Participates in staff meetings, training and orientation as assigned.
  
• Complies with HIPPA policies and standards regarding patient information and medical records.
  
• Assist with various projects as assigned by direct supervisor.
  
• Other duties as assigned.
  

PHYSICA.