Registered Nurse - Health Informatics

Nurse Position

The competent Nurse, in the same or similar clinical setting, practices independently and demonstrates an awareness of all relevant aspects of a situation. Provides routine and complex care, with the ability to on long-range goals or plans. Continues to develop the ability to cope with and manage contingencies of clinical nursing. Makes appropriate assignments and delegates to other care providers as a means to help manage the clinical situation.

Responsibilities

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients.
• Addresses increasingly complex psychological, emotional, cultural, and social needs of patient and families in accordance with their level of practice.
• Using the appropriate protocol, administers medications and treatments; monitors for side-effects and effectiveness of the treatment prescribed.
• Documents patient history, symptoms, medication, and care given.
• Assess learning needs and provides education to patients, family members and/or care givers; identify issues and resources.

Core Competencies

Standard I: Utilizes the Nursing Process

• Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, spiritual, and development needs of patient and families
• Communicates findings to appropriate healthcare team members
• Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice
• Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
• Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s)
• Performs timely reassessment and documentation
• Must be able to perform unit-specific competencies based on the specific patient care need for the designated unit's patient population

Standard II. Patient Throughput & Patient Flow Process

• Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
• Utilizes appropriate systems of communication and tools to facilitate the discharge process
• Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy

Standard III. Unit Operations

• Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
• Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
• Assesses departmental staffing needs; actively participates in resourcing efforts.
• Educates and trains others on the operations, ethics, and regulations within the industry

Standard IV. Safe Practice/Quality Care/Regulations

• Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
• Demonstrates accountability for nursing research and quality improvement activities
• Provides evidence-based nursing care
• Communicates patient information effectively across the continuum of care
• Educates and trains others on the operations, ethics, and regulations within the industry
• Knowledge of federal, state and local healthcare-related laws and regulations; ability to comply with these in healthcare practices and activities

Technical Competencies

Clinical Policies and Standards

• Follows a specific set of standards and associated clinical procedures
• Analyzes policy and standards documentation and ensures organizational compliance
• Provides feedback for improvement of procedures
• Assists in the development and implementation of specific procedures
• Works with control and monitoring mechanisms, tools and techniques

Health Information Documentation

• Shares experiences with maintaining paper and electronic patient documentation
• Walk through the steps and procedures for receiving, validating and updating patient records
• Describes the flow of information between various stations or units
• Discusses the functions, features and document flow of electronic documentation
• Transcribes verbal orders; explains techniques for ensuring their accuracy
• Explains health information documentation best practices and their rationale across health care practices

Medical Equipment

• Describes experience with basic medical equipment used in own unit or facility
• Uses standard diagnostic tools and techniques to resolves common equipment problems
• Educates patients about the appropriate use of home medical equipment
• Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
• Inspects, troubleshoots and evaluates incoming equipment

Medical Order Processing

• Shares experiences with processing medical orders for one or more groups of patients or conditions
• Describes functions and features of the system used to enter, validate, update and forward medical orders
• Discusses common errors, their sources and procedures for correcting
• Explains considerations for entering and following standing orders
• Differentiates between standing orders and preprinted orders and considerations for each

Patient Chart Reading and Interpretation

• Describes experiences in reading and interpreting patient charts for patients on unit and under own care
• Reviews patients' charts for completion and accuracy; identifies and alerts to mistakes or omissions
• Recognizes unexpected readings and alerts nursing or medical staff
• Relates examples of mis-readings or misinterpretations and lessons learned
• Reviews, discusses and validates own interpretation with others

Patient Safety

• Shares experiences with ensuring safety for one or more patient groups or settings
• Explains key features of safety guidelines and procedures for those groups and settings
• Listens and responds to safety inquiries from patients and family members
• Recognizes and addresses physiological and psychological signs of problems
• Describes considerations for patients who can cause to harm to self, versus harm to others
• Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real-time

Job Requirements

Education/Skills

• Bachelor of Science Degree in Nursing, preferred

Experience

• 1 year of experience in the related nursing specialty preferred

Licenses, Registrations, or Certifications

• BLS required
• RN License in state of employment or compact

In accordance with the CHRISTUS Health License, Certification and Registration Verification Policy, all Associates are required to obtain the required certifications for their respective positions within the designated time frame.

Work Schedule:

MULTIPLE SHIFTS AVAILABLE

Work Type:

Full Time

CHILDREN'S HOSPITAL OF SAN ANTONIO