RN Preadmission Testing

Job Description

Job Description:\n\n RN Preadmission Testing POSITION SUMMARY The Pre-Admission Testing (PAT) Registered Nurse is responsible for coordinating and conducting preoperative assessments to ensure patients are medically optimized and cleared for surgical or procedural interventions. This role emphasizes obtaining, reviewing, and validating all required medical clearances, diagnostics, and documentation in collaboration with surgeons, anesthesia providers, and other healthcare disciplines. The PAT RN helps reduce day-of-surgery cancellations and ensures patient safety and compliance with regulatory standards. Key Responsibilities Preoperative Assessment & EvaluationPerform comprehensive nursing assessments (in-person or via phone) including medical history, medication reconciliation, allergies, and risk screening.Identify comorbidities or risk factors that may impact surgical outcomes.Utilize standardized protocols to determine the need for additional testing or specialty clearance. Clearance Coordination (Core Function)Coordinate and obtain required medical clearances (e.g., cardiology, pulmonary, primary care, anticoagulation, anesthesia review).Review and validate that all medical clearances meet facility, anesthesia, and surgeon requirements.Track outstanding clearance items and follow up proactively to ensure completion prior to scheduled procedure.Communicate deficiencies or concerns to appropriate providers and escalate when necessary. Diagnostics & DocumentationOrder, review, and track preoperative tests (e.g., labs, EKGs, imaging) per protocol.Ensure all results are received, reviewed, and appropriately filed in the patient record.Collaborate with providers to address abnormal findings prior to surgery. Patient Education & PreparationProvide preoperative instructions, including NPO guidelines, medication management, and arrival expectations.Educate patients on procedure preparation and post-operative expectations.Ensure patient understanding and compliance with pre-surgical requirements. Interdisciplinary CollaborationServe as a liaison between patients, surgeons, anesthesia, primary care providers, and specialists.Communicate readiness status and address barriers to clearance.Participate in multidisciplinary planning for high-risk patients. Documentation & ComplianceMaintain accurate, timely, and complete documentation in the electronic health record (EHR).Ensure compliance with regulatory standards and organizational policies.Support audit readiness related to preoperative processes. Key CompetenciesClinical judgment: ability to identify risks and escalate concerns appropriately.Organization & follow-through: strong tracking and task management skills for clearances.Communication: effective coordination across multiple providers and departments.Attention to detail: ensuring all requirements are complete and accurate prior to surgery.Patient-centered care: ability to educate and guide patients through preoperative preparation. QUALIFICATIONS · Current Registered Nurse (RN) license in the state of Georgia. · Associate or Bachelor of Science in Nursing (BSN preferred). · Minimum 2–3 years of clinical nursing experience (perioperative, PACU, ICU, or med-surg preferred). · Strong knowledge of preoperative assessment and surgical risk factors. · Proficiency in EHR systems and clinical documentation.· Experience in pre-admission testing or surgical services. · Familiarity with anesthesia requirements and surgical clearance protocols. · Case management or care coordination experience. Work EnvironmentHospital ambulatory surgery center setting.Typically daytime hours with limited weekend/holiday requirements.Occasionally can be floated to other areas as needed.Combination of in-person patient interaction and telephone-based assessments. Performance MetricsReduction in day-of-surgery cancellations.Percentage of patients fully cleared prior to scheduled procedures.Turnaround time for clearance completion.Compliance with documentation and regulatory standards.Patient satisfaction with preoperative preparation. Knowledge, Skills and AbilitiesExcellent customer service skills.Reads and understands the English language.Ability to think critically and analytically with little or no supervisionAbility to work effectively in situations of high stress and conflict and communicate goals and outcomes.Ability to process information and prioritizePossesses exceptional verbal and written communication skillsPossesses independent work habits, is self-reliant and self-directedAbility to learn, adapt, and change as required by the job functionsAbility to maintain absolute confidentiality of material and information accessed and reviewedBasic computer literacyAbility to move freely, reach, bend, and complete light liftingAbility to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelinesAbility to maintain attendance to meet standard job practicesLicensureLicensed in good standing with the Georgia Board of Nursing and EKG Course.BCLSAdditional certifications may be required: ACLS, PALS, etc.Experience1 - 2 years experience preferred.Interpersonal skillsPositive and effective communication skillsEssential technical/motor skillsEssential physical requirementsHeavy: Exert 50 – 100 lb. of force occasionally and/or up to 30 lb. of force frequently - >75%Essential mental requirementsEssential sensory requirementsOtherBasic skills as defined by licensure/certification.Equipment used OTHER QUALIFICATIONSExposure to hazards (body fluid exposure level)Level IAge of Patient Populations ServedNeonates 1 - 30 daysInfants 30 days - 1 yearChildren 1 - 12 yearsAdolescents 13 - 18 yearsAdults 19 - 70 yearsGeriatrics - 70+ years STANDARDS OF PERFORMANCECRMC employees are devoted to serving our customers – including patients, physicians, fellow-employees and our community by adhering to the Standards of Performance. We are here to make all our customers feel special. Respectful and Confidential – Employee respects the rights of privacy of our patients. Ensures cultural differences are respected.Responsive – Employee responds quickly, graciously and appropriately to customer needs. Employee thanks customers.Gratitude and Attitude – Employee’s behavior shows that he/she believes that each of us controls our own attitude and that what is important is not so much as what happens to us, but how we choose to react to it.Pride, Ownership, and Image – Employee accepts all the rights and responsibilities of being a part of the CRMC family.Communication – Employee is personally accountable for positive communication with the customer – patients, family members and co-workers.Teamwork - Employee contributes positively to the CRMC team and is committed to treating coworkers with courtesy, honesty and respect. Employee abides by the Time and Attendance Policy. Employee has team pride in the purpose of our work – saving lives. JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDSBelow are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.Assesses and diagnoses patient and family needs in order to provide quality care to assigned patients as evidenced by: Performs admission assessment in accordance with specific unit standards.Identifies and documents patient/family/significant other teaching needs on admissionIdentifies discharge planning needs of patient/family/significant other on admission.Verification of patient identity.Verification of patient allergies, NPO status.Checks current history and physical, laboratory results, the execution of pre-procedure orders and results of ordered diagnostics, if applicable. Develops, discusses, and communicates a realistic problem list (plan of care) in collaboration with each patient/family/significant other in order to address all identified needs as evidenced by: Plan of care will include nursing diagnosis statement for each identified problem.Develops patient/family/significant other teaching and discharge plan as per unit standard.Assembles necessary supplies/equipment prior to start of case.Checks for availability and proper condition of necessary supplies and equipment. Demonstrates the skills and judgment necessary to implement medical plan of care, nursing interventions, and procedures as necessary for the care of the patient as evidenced by: Demonstrates knowledge of hospital policies and procedures for administering, transcribing, and recording medications. Demonstrates knowledge of commonly used meds: action, dose, and side effects.Observes five Rs for administering meds: right patient, right drug, right dose, right method, right time.Demonstrates proper procedures in all methods of medication administration.Administers blood and blood products following hospital policy and procedures.Demonstrates the ability to do blood draws properly. Complete an EKG on patients. Initiates and maintains IV access according to hospital policy and procedures.Assesses and documents IV site per unit standard.Identifies priorities and executes nursing care appropriately.Provides emotional support and comfort measures.Correctly collects and accurately labels specimens. Evaluates and reassesses the identified problems, care provided and patient's responses in order to meet patient and family needs to ensure overall quality of care delivered as evidenced by: Reassessment of plan of care is done per unit standard.Assesses the patient/significant other's response to teaching plan in order to evaluate the effectiveness of the plan.Based on reassessment, plan of care will remain the same or be modified to meet the patient/significant other's identified needs.Documents outcomes of patient care. Maintains up to date and accurate documentation of nursing care provided to ensure the integration of information for use by the healthcare team, in order to ensure quality care as evidenced by: Nursing assessment is complete and accurate per unit standard.Day surgery record/form accurately reflects nursing interventions and medical plan of care.Discharge plan and documentation accurately reflects patient and/or significant other's ability to manage care after discharge. Referrals are made based on identified needs.Interagency communication referral forms are complete and accurate.Documents use of narcotics according to hospital policy and procedure.Accurately and promptly documents unusual occurrences notes during the patient stay. Maintains current knowledge/certification/licensure. Pursues professional growth and development as evidenced by: Practices within legal boundaries of nurse practice act and according to hospital policy and procedures.Attends continuing education programs in order to maintain licensure. Attends hospital-sponsored training programs as required by department. Performs all responsibilities/duties required by the unit/department as defined in the scope of service, to ensure that the unique nature of the patient is addressed as evidenced by: Demonstrates the ability to rapidly assess the patient, differentiating between long and short-term needs.Patients are discharged from the unit/department with consideration given to age and mobility.Discharge instructions are thorough and clear. Signatures obtained as per policy.Patients prepared for their procedure(s) and chart completed in timely manner.Properly demonstrates ability to recognize cardiac rhythms and to treat arrhythmias appropriately. Attends all required safety training programs and can describe his/her responsibilities related to general safety, department/service safety, and specific job related hazards. Follows the hospital exposure control plans/blood borne and airborne pathogens as evidenced by: Demonstrates knowledge of techniques, procedures, and correct use of protective barrier equipment.Attends annual education programs.Wears and/or uses appropriate safety equipment. Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment as evidenced by: Interacts with all of the above in a considerate, helpful, and courteous manner as observed by nurse manager and peers.Fosters mature professional relationships with fellow employees in a courteous, friendly manner as measured by management observation and peer input.Maintains professional composure and confidence during stressful situations.Maintains open communication using appropriate chain of command regarding issues.Conducts all work activities with respect for rights and wishes of patients, visitors, families, and fellow employees.Maintains confidentiality of all hospital and patient information at all times.Presents neat appearance in proper attire and identification as required by hospital policy.Displays a positive attitude that contributes to the overall customer service program in place at the hospital. Assumes all other duties and responsibilities as necessary. Meets clinical competencies for age-specific competencies as evidenced during skill competency check-offs. REGULATORY COMPLIANCEBelow are any additional competencies as related to regulatory compliance that are specific to the job title and not listed in the other sections of the document. EDUCATION AND COMPETENCY Attends all mandatory and department-specific education and training programs as required. Attends all required education and training and can describe his/her responsibilities related to department safety and specific job related hazard. Has met all required competencies for the evaluation period as evidenced by job specific competency evaluations. Participate in all required Coffee Regional Medical Center Training. Complete all assigned Health Stream modules in a timely manner.