Top 5 Clinical documentation specialist Jobs in Watertown, Sd

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clinical documentation specialist jobs near watertown, sd

Staff RN - ECMO Spec / FT, nights

Children's Nebraska -
United States

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Job Details

Full-time

Benefits

Flexible schedule

Qualifications

RN License
BLS Certification

Full Job Description

Schedule: FT, nights

At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview
Coordinates professional nursing and individualized, family centered care to pediatric patients/families through the use of the nursing process and clinical skills in accordance with standards and hospital policies and procedures. As an ECMO Specialist who has completed specialized training in the operation, maintenance and application of circulatory technology (perform neonatal, pediatric and adult ECMO at Children's) requiring extracorporeal membrane support. Demonstrates expanded knowledge base through participation in ECMO program projects and activities. Flexible schedule to cover the needs of the ECMO patient during an ECMO run. Varied schedules to include weekend and holiday patterns, 7am-7pm or 7pm-7am.

Essential Functions

Conducts individualized age-specific patient/family assessments according to defined unit scope and nursing practice standards, appropriate collaborative problems (CPG's)/nursing diagnoses(ND's), or protocols. (Individualized refers to the patient’s developmental, cognitive, cultural, psychosocial, spiritual, and educational/family influences and physical/medical care needs.) Admission Assessment: • Collects and documents data related to patient’s individualized care. • Demonstrates age-specific competency in assessment of patients by the ability to obtain and interpret information in terms of the patient needs, knowledge of growth and development, and understanding of the range of treatment needed by these patients. • Assesses patient/family need for education and uses an individualized approach in delivery style. • Assesses family expectations for, and involvement in the assessment and continuous care or treatment of the patient. • Identifies nursing diagnoses, collaborative problems, and/or protocols for each patient, based on assessment, at the time of admission. Shift Assessment/Reassessment: • Performs reassessment based on unit standards, CPG's/ND's, protocols and changes in patient condition. Communicates changes to appropriate persons (MD, CNC, family) as indicated Manages the ongoing process of healthcare delivery to ECMO patients and families: Assessment and Planning: • Participates in the evaluation of patients as potential ECMO candidates. • Works in collaboration with Perfusion to manage ECMO cannulation, decannulation and stabilization procedures. • Prepares and operates clinical equipment and circuitry per ECMO procedures/policies. • Accurately assess and review with physician and ECMO team, pathophysiological changes within the patient and ECMO circuit. Differentiates patient versus circuit problems and intervenes appropriately. • Based on clinical assessments, contributes to the development of individualized age and developmental appropriate plan of care with patient and family. • Participates in ECMO case review and assists team members in defining learning outcomes. • Participates in the collection/review of quality improvement initiatives and data for the ECMO program and ELSO data.
Develops individualized patient/family plan of care using CPG/ND’s, and practice guidelines/protocols to meet identified needs. (Plan of Care includes current and anticipated actions focused on care, education, discharge needs.) • Utilizes assessment data from the healthcare team to individualize appropriate goals and actions for the patient, including collaboration with the family and the healthcare team. • Utilizes individualized assessment data to develop the patient/family’s plan of care. • Formulates goals and outcomes based on assessment data. • Revises plan of care based on patient’s condition, interdisciplinary input, and family needs. • Demonstrates ability to prioritize patient interventions based on assessments/reassessments. Uses available child care partners to support patient care needs as appropriate.
(A) Implements and evaluates nursing actions in accordance with the individualized patient/family plan of care and patient condition/needs. • Oversees that the nursing and interdisciplinary plan of care/goals are coordinated, implemented, evaluated, and revised as needed. Identifies the need for interdisciplinary involvement/outside resources and follows through. Uses appropriate resources (CNC, CNS/Educator, PCM, MD, etc) to ensure that clinical outcomes are achieved. • Incorporates critical thinking into the delivery of clinical skills and in analyzing patient response to orders, tests, labs, medications, and treatments. • Demonstrates clinical competence in administering interventions according to identified standards and age specific needs. • Provides and/or coordinates with other disciplines patient/family education according to identified care needs, considering assessment of patient/family’s readiness to learn (B) Implements Plan of Care to ECMO patients and families: • Works in collaboration with ECMO Team to assess clinical status and related lab results (ACT levels, blood gases and metabolic status). Notifies ECMO physician of clinical status/lab values, performing appropriate interventions and implementing physician orders within established guidelines/ECMO policy and procedures. • Manages ECMO flow in relationship to established clinical parameters. Reviews daily parameters with the ECMO Team. • Demonstrate proper blood sampling techniques from the ECMO circuit. • Perform, manage and troubleshoot activated clotting times (ACT) as per ECMO protocol including management and administration of heparin drip per ECMO protocol. • Administers all blood products/medications appropriately when ordered to be given through the ECMO circuit. • Maintains and effectively assesses ECMO circuit function. Performs all circulatory technical skill with efficiency, accuracy and safety while anticipating, troubleshooting, intervening and managing crises/emergency situations according to policy and procedure maintaining professional composure. • Role models proficiency in documenting appropriately by assimilating information related to interventions, plan of care and anticipated outcomes accurately into all ECMO records and teaching documents. • Participates in patient management discussions to include: communicating anticipated patient needs/plan of care, suggesting clinical management options and providing feedback for interventions that improve patient outcomes.
Documentation reflects accurate assessment/evaluation, modification, and patient’s response to therapy, changes in condition, and therapeutic interventions/procedures. • Entries in the medical record follow hospital policy (i.e., date, time, use of appropriate abbreviations, and legibility). • Documentation is completed within established timeframes including, but not limited to: Admission Assessment form, daily Patient Flowsheet, Peripheral IV Flowsheet, Family Education Record, and Interdisciplinary Goals. • Reviews and updates computerized care plan to accurately reflect the plan of care. • Completes computerized documentation within established timeframes, including, but not limited to: Medication Administration Record, Allergies, Patient Information, etc. • Completes and verifies accurate order entry in the computerized care plan. • Ensures that discharge instructions clearly state patient care needs after discharge.
Based on departmental/organizational need may be required to participate in Transplant program functions
Accepts assignments to float to other units utilizing clinical skill sets and appropriate resources, delegating when appropriate. Professionally supports the assigned unit, as seen through interactions with patients, families, area staff, colleagues and others.
Accepts assignment to mentor student nurse observation experience in unit.
Accepts assignments to share/teach knowledge and provide clinical support as a relief preceptor for new staff.

Education Qualifications

Graduate of an accredited school of nursing. Required

Experience Qualifications

Experience with pediatric patients Preferred and
Previous experience with EPIC Preferred and
Previous ECMO experience Preferred and
Minimum of two years recent (in the past year) Level III NICU or PICU experience required or with equivalent critical care experience or minimum of two years’ experience in critical care Required

Skills and Abilities

Must be able to perform a variety of duties, often changing from one task to another of a different nature, without loss of efficiency or composure, and be able to perform under stressful conditions when confronted with multiple requests, demonstrating prioritizing skills.
Excellent communication, assessment and patient care skills, as well as flexibility and ability to function in a high stress environment.
Flexibility to work full time day/night shifts with possible over time during ECMO run.

Licenses and Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Required and
Specialty pediatric certification Preferred and
Current and valid Basic Life Support (BLS) through the American Heart Association Required and

Children’s is the very best for kids and the very best for your career! At Children’s, we put YOU first so together, we can improve the life of every child!

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clinical documentation specialist jobs in watertown, sd

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