Job detail

Registered Nurse Pre-Admission/Chart Review - ASC - Part Time

Prevea Health

#Registered Nurse #Patient Assessment #Medical Records #EMR #BLS #CPR #Healthcare #ASC #Pre-Admission

Quick overview

Conducts comprehensive pre-operative patient assessments and medical record reviews to ensure surgical readiness and regulatory compliance. Coordinates with surgeons and anesthesiologists to manage patient instructions, order entry, and pre-surgical clearances.

Requirements summary

Requires a nursing degree from an accredited program and at least 2 years of experience in peri-operative or operating room nursing. Must hold a current Wisconsin RN license and CPR/BLS certification.

bachelor degreeWritten CommunicationVerbal CommunicationProblem SolvingPatient CarePatient EducationChart ReviewInterdisciplinary CollaborationClinical KnowledgeMedical DocumentationMedication ManagementEMR ProficiencyPre-operative Assessment

Job description

RN Pre-Admission/Chart Review

This position will work 20 hours per week - distribution of hours is flexible

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Come work where we specialize in you!
We have nearly 2,000 reasons for you to consider a career with Prevea Health—they're our employees.
We're an organization that values kindness, responsibility, inclusivity, wellness and inspiration.
At Prevea, we provide continuous education, training and support so every member of the team contributes to our success.
Together we are the best place to get care and the best place to give care.

Job Summary At Prevea Health The RN Pre-Admission/Chart Review plays a crucial role in ensuring a smooth and efficient pre-operative process by conducting comprehensive reviews of patient medical records prior to surgical or procedural admissions. This position requires strong clinical knowledge, attention to detail, and the ability to collaborate with interdisciplinary teams to optimize patient outcomes.

What you will do
Conducts pre-op phone call history prior to surgery with data collection and assessment interview, instructions for NPO status, arrival time on day of surgery, medication instruction and all other information deemed necessary to complete this process including consulting with anesthesiologist and surgeon with questions and coordinating special needs.
Review pre-admission charts to ensure completeness, accuracy, and compliance with facility and regulatory standards by assessing patient history, laboratory results, diagnostic reports, and physician orders to verify all necessary documentation is included. Identify and address missing or incomplete information by coordinating with physicians, nursing staff, or administrative teams to obtain required documentation.
Document all call encounters using the facility Electronic Medical Records (EMR) system. Update physician order sets, smart phrases, and discharge instructions in EMR.
Conduct pre-op order entry based on surgeon preference/standing orders.
Communicate special requests and pertinent information to appropriate personnel, provide patient education as needed, and coordinate with staff, patients, physicians, and clinics to facilitate the pre-admission process.
Communicate with patients regarding pre-admission instructions, medication management, and necessary pre-procedure requirements.
Ensure proper pre-surgical or pre-procedural clearances are met, including anesthesia evaluations, specialist consultations, and medical history updates.

Registered Nurse Pre-Admission/Chart Review - ASC - Part Time

Quick overview

Requirements summary

Job description

RN Pre-Admission/Chart Review

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