LPN Scribe - Denham Springs Job Listing at Baton Rouge General in Denham Springs, LA (Job ID 1996807045)

Description

JOB PURPOSE & MISSION 

Administers nursing care to designated patients under the direction/supervision of the physician, clinic RN/or manager. Supports physician with clinical documentation into the electronic medical record. Performs a variety of direct and indirect patient care duties in accordance with the needs of the age population served, as defined in the department's scope of service.

Essential Job Functions include, but are not limited to:  

1. Collects data essential to assessment and indicates deviations from normal to the physician. 

• Completes collection of assessment data. 
• Assist with reassessing patient according to unit standards and/or hospital policy, as patient needs dictate and reports pertinent changes in patient status to the R.N. or Physician. 
• Completes documentation 100% of the time. 

2. Performs patient care according to standards of care and the needs of the patient. 

• Collects data from patients and family. 
• Teaches family and patients. 
• Completely and accurately documents medication administration, treatments, collected data, interventions, and unusual occurrences, as observed by chart review. 
• Administers medications as ordered by physician. 
• Performs treatments as prescribed by physician. 
• Directs and assists ancillary nursing staff with assigned duties. 
• Monitors IVs and blood for proper functioning and reports any untoward side effect to the R.N. or physician immediately. 
• Starts IVs prn and as ordered by physician. 

3. Work directly with physician to ensure the patient visit is appropriately documented 

• Accompany physician into the exam room for the patient visit documenting in the electronic medical record (EMR) all aspects of care including, but not limited to, chief complaint, history of presenting illness, physical exam and patient plan as directed by the physician. 
• Ensure optimization of physician practice by keeping current with EMR flow and templates. 

4. Performs all other duties as assigned. 

JOB REQUIREMENTS  

Experience 

Required – none 

Preferred – 1 year of experience 

Education 

Required – none 

Certifications & Licensure 

Required – Current Louisiana LPN licensure 

Special Skills or Knowledge 

Required – none 

HIPAA & SAFETY REQUIREMENTS 

HIPAA - Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records without limitation bother paper and electronic, patient demographics, lab and radiology results, surgery/appointment schedules, medical records related to quality/data, patient financial and 3rd party billing information, patients related complaints, information related to patient location, patients' religious beliefs and/or research information. 

SAFETY - Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wastes, sharps and linens, PPE, exposure control plan, hand washing, environment of care, patient identification, administers medications, receives orders for patients, monitors clinical alarms, and collects blood samples. 

PERFORMANCE CRITERIA & STANDARDS 

Everyday Excellence Values - Employee demonstrates Everyday Excellence values in the day-to-day performance of their job.   

• Demonstrates courtesy and caring to each other, patients and their families, physicians, and the community.  
• Takes initiative in living our Everyday Excellence values and vital signs.  
• Takes initiative in identifying customer needs before the customer asks.  
• Participates in teamwork willingly and with enthusiasm.  
• Demonstrates respect for the dignity and privacy needs of customers through personal action and attention to the environment of care.  
• Keeps customers informed, answers customer questions and anticipates information needs of customers  

Corporate Compliance - Employee demonstrates commitment to the Code of Conduct, Conflict of Interest Guidelines and the GHS Corporate Compliance Guidelines.  

• Practices diligence in fulfilling the regulatory and legal requirements of the position and department.  

• Maintains accurate and reliable patient/organizational records.  
• Maintains professional relationships with appropriate officials; communicates honestly and completely; behaves in a fair and nondiscriminatory manner in all professional contacts.  

Personal Achievement- Employee demonstrates initiative in achieving work goals and meeting personal objectives.  

• Uses accepted procedures and practices to complete assignments. Uses creative and proactive solutions to achieve objectives even when workload and demands are high.  
• Adheres to high moral principles of honesty, loyalty, sincerity, and fairness.  
• Upholds the ethical standards of the organization.  

Performance Improvement - Employee actively participates in Performance Improvement activities and incorporates quality improvement standards in his/her job performance.  

• Optimizes talents, skills, and abilities in achieving excellence in meeting and exceeding customer expectations.  
• Initiates or redesigns to continuously improve work processes.  
• Contributes ideas and suggestions to improve approaches to work processes.  
• Willingly participates in organization and/or department quality initiatives.  

Cost Management - Employee demonstrates effective cost management practices.  

• Effectively manages time and resources  
• Makes conscious effort to effectively utilize the resources of the organization — material, human, and financial.  
• Consistently looks for and uses resource saving processes.  

Patient & Employee Safety - Employee actively participates in and demonstrates effective patient and employee safety practices.  

• Employee effectively communicates, demonstrates, coordinates and emphasizes patient and employee safety.  
• Employee proactively reports errors, potential errors, injuries or potential injuries.  
• Employee demonstrates departmental specific patient and employee safety standards at all times.  
• Employee demonstrates the use of proper safety techniques, equipment and devices and follows safety policies, procedures and plans.