Clinical documentation specialist [h1.location_city]

SUMMARY : Under general supervision, provides nursing care to patients, including medications and treatment. Plans, implements, and evaluates patient care and performs related duties as required. The CN II level is the journey level class where incumbents have had the required professional nursing experience and are capable of independently performing the full range of clinical nursing services involving patient care. Clinical Nurse II's may supervise the work of professional and paraprofessional staff of the unit to which assigned.

DUTIES & ESSENTIAL JOB FUNCTIONS : NOTE : The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Accompanies, assists, and represents the needs of patients to other providers.

2. Accurately provide care with respect to medication administration, skin and wound care, ADL's and other essential patient care related activities.

3. Develops, implements, evaluates and makes modifications in the nursing care plan; prepares required records and reports.

4. Gathers and assess information about patients to meet nursing needs; assists and consults with physician in the performance of procedures and diagnostic tests; contracts physicians and / or other departments to obtain or provide patient information.

5. May provide oversight to staff who monitor telemetry systems; alerts primary nurse of changes in underlying rhythms and of any life threatening arrhythmias that may develop; interprets and posts telemetry strips at the hours specified; admits and discharges patients with telemetry units as appropriate.

6. Organizes, supervises, makes adjustments and accepts responsibility for the quality of care provided patients by co-workers for a given work period; at the level II assumes responsibility as a team leader or a charge nurse when assigned.

7. Participates in promoting a healthful, safe, and therapeutic environment for patient and families; set up and controls the environment essential for infection control.

8. Participates in the implementation of patient care standards, infection control standards and quality assurance criteria; assist with conducting studies; participates in unit and other meetings.

9. Provides and evaluates patient care established standards and criteria in conformity with the nursing care plan. Monitors patients for significant and critical changes and initiates procedures as required; documents care given according to set standards and at required intervals. Interprets and explains procedures, regimens, and services to patients and families; teaches patients and family members health care and disease prevention techniques. Prepares patients and / or area for procedures and operations; assists physicians; uses instruments and equipment related to the area of assignment.

Minimum Qualifications :

Education : Graduate of an accredited Nursing Program required; Bachelor's degree in Nursing preferred.

Minimum Experience : Six months experience as a Clinical Nurse I with AHS or the equivalent of one year full time recent experience at a comparable level in a minimum 100-bed hospital or in the area of specialty; (if experience is not recent, completion of an approved refresher course may be acceptable).

Preferred Licenses / Certifications : TNCC -Trauma Nurse Core Course (For Emergency department only).

Required Licenses / Certifications : Valid license to practice as a Registered Nurse in the State Of California.

Preferred License / Certifications : CCRN - Critical Care Registered Nurse.

Required Licenses / Certifications : ACLS - Advanced Cardiac Life Support Certification - issued by AHA - American Heart Association, may be required per facility or unit / department specialty according to patient care policies.

Required Licenses / Certifications : Acquire certification in chemotherapy within one year of hire (certain positions only).

Required Licenses / Certifications - Acquire ONS certification within one year of hire (inpatient med tele / oncology department).

Required Licenses / Certifications : BLS - Basic Life Support Certification issued by the American Heart Association. Other advanced life support certifications may be required per unit / department specialty according to patient care policies.

Required Licenses / Certifications : CEN - Certified Emergency Nurse is desirable (for Emergency Department positions).

Required Licenses / Certifications : Certification as a Public Health Nurse in the State of California (required for certain positions).

Required Licenses / Certifications : Completion of Perinatal Safety Modules within 3 months of hire. Evidence of completion and continuing annual competency must be in the employee file and / or AHS's learning management system (LMS) (for certain positions).

Required Licenses / Certifications : Coronary Care Unit certification (required for certain positions at Fairmont Hospital's Monitoring Unit).

Required Licenses / Certifications : TEAM Training (required for all positions at John George Psychiatric Pavilion; and required for certain positions in the Emergency Department).

Required Licenses / Certifications : NRP - Neonatal Resuscitation Program Certification- AHA American Heart Association (required per unit / department specialty according to patient care policies).

Required Licenses / Certifications : PALS - Pediatric Advanced Life Support Certification- AHA American Heart Association (Required for Emergency Department or if overseeing or providing pediatric care on a regular basis).