Under the supervision and direction of a Registered Nurse, the nursing assistant/unit secretary performs various duties in the care and treatment of patients in accordance with established methods and procedures.
Past work experience related to nursing or medical records is desirable, prefer one year experience as a Nursing Unit administrative or Certified Nursing Assistant.Ability to work under pressure while maintaining a professional manner with visitors, hospital staff, and physicians. Ability to organize and complete multiple tasks in a limited time.
Consistently and independently provides direct patient care including bathing, mouth care, skin care, and ensures clean linen. Attentive to all of the patient's personal needs Patient safety: Maintains a safe, clean environment for patients. Reports maintenance needs. Follows standard precautions and isolation protocols. Follows fall prevention policy. Follows standards for prevention of skin breakdown. Adheres to all established cleaning guidelines. Submits and tracks maintenance work orders for physical plant issues on the nursing unit. Promptly answers pneumatic tube system and utilizes appropriate follow-up. Documentation: Accurately and promptly documents patient data including patient care, treatments, vital signs, and intake and output. Maintains paper charts in compliance with medical records guidelines. Ensures integrity of record, including patient identification on all chart forms. Ensures complete chart is sent with patient at time of transfer to another department, transfer to another facility or at discharge, to include both paper chart and electronic medical record documents. Ensures nursing unit is constantly prepared for an EMR downtime event, including maintenance of identified downtime devices and equipment, and keeping an adequate supply of all necessary materials to support the downtime process. Collection of specimens: Collects specimens following policy. Aware of specimens needed and is active in obtaining. Unit organization: Prepares patient rooms and beds for receiving patient admissions, returning surgical patients, transfers, or emergencies. Maintains safe, clean and organized patient/work area and . Maintains inventory of supplies: , forms and materials for unit and keeps inventory current. Assures prompt, appropriate storage of all supplies. Requests equipment and supplies needed to carry out physicians orders and ensures delivery. Responsible for assisting unit manager with identifying broken/problematic EMR devices (WOWs, tablets, wall PCs, desktop PCs), label printers, fax/printers and other equipment. Independently reports equipment issues to appropriate departments using established procedures, and tracks resolution of reported problems, escalating barriers to unit manager as needed. Care and treatment: Assists with positioning, turning, lifting, and ambulating patients. Applies special equipment and completes treatments as directed. Accuchecks completed as directed. Nutritional care: Distributes food trays / sets up trays promptly. Assists or feeds patients as necessary. Removes trays in a timely manner and documents accurate intake. Distributes drinking water and other nourishment to patients throughout the shift. Patient rounds: Completes purposeful hourly rounds to assigned patients and anticipates patients needs. Responds promptly to call lights, patient requests, and initiates interventions. Communication: Proficient in receiving, greeting, and directing patients, visitors, and hospital personnel, responding to routine inquiries and responding to questions. Quickly determines the need and responds accordingly. Promptly reports any changes observed in the condition or behavior of the patient to the nurse. Gives accurate Bedside Report as handoff to oncoming shift. Aware of changes in patient care plan and communicates this when handing off. Promptly monitors physician/provider orders in the electronic medical record (EMR) when necessary. Schedules studies and procedures appropriately, when needed. Communicates consults promptly and appropriately according to established procedure. Pages/contacts physician/provider when needed. Regularly reviews tasks lists for new and stat patient orders and alerts RN caring for patient of these orders on an ongoing basis. Professional Accountability: Actively assists others and accepts additional duties or assignments. Timely completion of assigned education and annual competencies. Actively engaged in unit based councils and performance improvement. Recognizes unit needs and works to help facilitate solutions. Shows flexibility and transitions between the role of CNA and US per the needs of the unit. Recognizes the Unit Secretary role as it relates to the overall function of the department, patient care, customer service and the business of healthcare.
Competencies and skills:Essential:
- C.N.A. - Certified Nursing Assistant
- BLS - Basic Life Saving certification
- Clear Communication Skills Both Written And Verbal
- Able To Keep Confidential Information Regarding Patients, Team Members
- Able To Withstand Crisis Situations
- Has Skills To Provides Customer Service To Patients, Team Members And Visitors
- Knowledge And Experience With Electronic Health Records
- Experience With Excel, Power Point, Word, Visio, Etc.
- High school graduate or equivalent
12 Hour Shifts: 7A-7P/7P-7A Rotating shifts, nights, weekend, and holidays