Description

POSITION SUMMARY

This position is responsible for providing quality care to patients undergoing surgical intervention in the area of preadmission, admitting, recovery, and discharge. The RN assesses, plans, implements and evaluates the care of the patient. The RN will ensure that the patient is prepared for discharge by providing the necessary education to the patient and responsible caregiver.

ESSENTIAL JOB FUNCTIONS

Pre-Admitting

1. Health history obtained from patient or patient representative and documented on proper forms or records. Provides information to patient regarding patient rights and responsibilities. Provides instructions/guidelines for pre-surgical preparation.
2. Records critical patient information into patient’s case line.
3. Alerts supervisor or director of nursing regarding suitability for surgery when concerns arise about a patient’s health history.
4. Follows guidelines regarding need for pre-surgical anesthesia consults. Obtains appropriate medical records needed for consult and provides this information to the anesthesia chief of the day.

Admitting

1. Receives patient into pre-operative area, assesses vital signs, and assists patient with pre-operative preparation.
2. Reviews chart for complete and proper paperwork. Reviews patient health questionnaire. Completes practitioners’ orders for pre-surgical prep.
3. Provides patient-centered interactions, patient education, and answers questions.
4. Documents all procedures/tasks, medication administration, and assessments thoroughly and accurately on appropriate forms or records.
5. Observes for changes in patient condition. Provides any needed interventions or urgent care to maintain patient safety. Notifies practitioner of changes promptly. Documents any interventions provided to patient, the patient’s condition, and the notification of practitioner on proper forms or records.

Recovery

1. Receives patients into recovery room. Receives report from OR staff and anesthesia practitioner. Notes and documents level of consciousness, adequacy of respiration, and vital signs. Patients are assessed every 5 minutes until stable and then every 15-30 minutes until deemed stable and discharge criteria has been met.
2. Provides nursing care including patient assessment, suctioning (if needed), dressing status, medication administration, and implementation of practitioners’ orders.
3. Thorough and accurate documentation of vital signs, patient assessment, suctioning (if needed), dressing status, medication administration, and implementation of practitioners’ orders. Photo copies all prescriptions written by the practitioner and places copy in the chart. Documents presence of family and practitioner visits to the bedside.
4. Observes for changes in patient condition. Provides any needed interventions or urgent care to maintain patient safety. Notifies practitioner of changes promptly. Documents any interventions provided to patient, the patient’s condition, and the notification of practitioner on proper forms or records.
5. Determines when patient is ready for discharge according to facility guidelines.

Discharge

1. Prepares patient for discharge including assisting with redressing, checking surgical dressing, and reviewing discharge instructions and medications with the patient and patient’s escort.
2. Assists patients safely to their vehicle, ensuring the patient is discharged to a responsible adult.
3. Thorough and accurate documentation of all discharge procedures.

OTHER JOB FUNCTIONS

1. Attends staff meetings, in-services, trainings, conferences, or other company events as requested.
2. Performs other duties as assigned by Director of Nursing or Administrator.

Requirements

QUALIFICATIONS

Education, License, and Experience

• Graduate of an accredited school of professional nursing AND Licensed Registered Nurse (RN) in the State of Washington.
• Certified in basic CPR for Healthcare professionals.
• Current PALS certification preferred (post hire advancement to PALS will be expected).
• Current ACLS certification preferred (post hire advancement to ACLS will be expected).
• Experience working in a surgery setting preferred.
• The Board of Managers or Licensing Council may periodically determine other qualifications.

Knowledge, Skills and Abilities

• Must have body of nursing knowledge and ability to demonstrate sound judgment while giving direct or indirect patient care.
• Strong clinical nursing skills to effectively provide high quality nursing care.
• Possess strong organizational skills and a clear understanding of the importance of efficiency and cost effectiveness in an outpatient surgery center.
• Ability to make quick assessments of patients and handle emergency situations appropriately.
• Strong ability to work collaboratively with others in a team setting.
• Excellent verbal and written communication skills.
• Ability to work with diverse groups.
• Ability to provide dependable, on-time attendance.

GENERAL PHYSICAL REQUIREMENTS

Most of work is performed in medical clinic setting which requires the ability to freely move about the facility for patient care. May require standing for long periods of time. Must be able to assist the movement of patients which includes the ability to lift up to 25 pounds without assistance and the ability to push/pull patients in wheelchairs or on gurneys. Position requires hand manipulative skills for word processing and writing. Must be able to hear verbal conversations over the phone and in-person with background noise. Must be able to consistently identify objects and persons at a distance and read fine print on various forms. May have exposure to patients with communicable diseases. May have exposure to blood and/or other body fluids.