Clinical Documentation Specialist

Office Nurse

The office nurse will provide clinical support to the physician as needed and will provide direct nursing care to patients. Duties include performing as a member of the team and assisting in the administration and maintenance of an efficiently operated clinic. Accurately performs and documents assigned duties under the direction and supervision of the physician in accordance with the medical model of care as provided by the State Board of Nursing. Initiates implementation of processes and|or has access to all operational components of the office as required by daily operations. Education: Nursing Diploma or Associate Degree of Nursing required. Licensure/Certification: Current and valid Registered nurse license in the Commonwealth of Virginia or from a state that is part of a Compact agreement with Virginia required. CPR certified. Experience: Minimum of 5 years' experience in a clinical setting preferred. Essential Job Duties: Participates in educational and training programs to meet Augusta Health requirements. Ability to work effectively as a team player. Arrange for follow-up care and appointments for patients and maintain communication with patients/families in other facilities. Arrange and track patient referrals to specialty physicians. Assist with blood pressure check visits and medicine reviews. Assist with routine office duties to include ordering medical supplies, maintaining appropriate inventory, scheduling patients, answering telephones, etc. Ability to provide care and communicate to all age groups. Collect, label and prepare specimens for lab delivery. Perform nursing triage for acute visit requests from patients. Conduct annual physical exam interviews and assist with exams. Documents all patient care and relevant data accurately and systematically. Participates in staff meetings. Provide assistance to the provider as needed in examinations and special procedures. Respects physician preferences and anticipates physician's needs. Provide direct routine nursing care to patients according to physician's instructions. - Assess the patient for needs specific to age, general condition, psychosocial, emotional, physical, spiritual status and visit reason or surgery to be performed. Completes written assessment and documents specific needs identified. Plans for the care of the patient by obtaining appropriate supplies and equipment in advance, uses appropriate positioning aids. Anticipates patient needs and changing conditions necessitating additional, different supplies. - Monitors and maintains safe comfortable environment, assists safe transport to and from table/bed/chair - Maintains, monitors and initiates correction of breaks in aseptic technique - Compiles with Augusta Health policies and procedures for handling hazardous materials, fall precautions, infection control, electrical and fire safety. - Evaluates care given based on specific needs and projected outcomes. Responsible, versatile individual willing to accept a variety of responsibilities. Provide pre and post-procedural nursing care to patients including administration of medication, local lab tests, venipuncture, EKGs and assessment of patient's status. Assist physician in monitoring patients on prescriptions Assumes a leadership role in absence of a senior staff member Maintains confidentiality of patients Coordinates and observes activities of supportive clinical staff, makes recommendations in the quality and effectiveness of care provided. Assist other personnel in administration of total patient care. Performs procedures under the provider's guidance Accepts and documents verbal orders /critical results according to Augusta Health Policy. Performs waived testing according to the Augusta Health Policy and Procedure. Administers medications per the guidelines for Augusta Health. Schedule and track wellness initiatives for patients (labs, coloscopies, immunizations, mammograms) Process prescription refills Some benefits of working at Augusta Health include: Generous paid time off to promote work life balance Competitive Pay Retirement Plan Medical, Dental, and Vision Benefits Free onsite parking Tuition reimbursement Onsite childcare Company Information:Augusta Health is a mission-driven, independent, nonprofit, community health system located in Fishersville Virginia in Virginia's scenic Shenandoah Valley. Augusta Health offers a full continuum of inpatient and outpatient services which includes Augusta Medical Center a 255 bed inpatient facility and Augusta Medical Group which is comprised of 40 practice locations and four urgent care locations.Equal Opportunity:Augusta Health recruits, hires and promotes qualified candidates for employment without regard to age, color, disability, gender identity or expression, marital status, national or ethnic origin, political affiliation, race, religion, sex (including pregnancy), sexual orientation, veteran or military discharge status, and family medical or genetic information.