Registered Nurse Pre-AdmissionChart Review - ASC - Part Time

RN Pre-Admission/Chart Review

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

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.
• Document findings and discrepancies in electronic medical records (EMR) and notify relevant healthcare providers of necessary corrections.
• Educate patients on pre-operative and post-operative care as needed.

Education Qualifications

• Graduation from an accredited and approved Nursing program Required
• Bachelor's Degree in Nursing Preferred

Experience Qualifications

• 2 years experience in peri-operative or operative room nursing Required

Skills and Abilities

• Knowledge of principles and skills needed to provide patient care.
• Knowledge of medical equipment and instruments to provide patient care.
• Knowledge of common safety hazards and precautions to establish a safe work environment.
• Fosters work and patient relationships through excellent interpersonal skills and behaviors.
• Ability to prioritize work and meet changing demands.
• Ability to work under stressful or emergency situations with high concentration and energy level.
• Possess skills to effectively problem solve.
• Proficient in the use of EMR systems, computer, phone, and office equipment.
• Possess effective written and verbal communication.

Licenses and Certifications

• Current Wisconsin RN license (or compact equivalent; nurses must maintain or update their primary state of residence to Wisconsin to ensure continued eligibility under the compact) Upon Hire Required
• CPR/BLS Certification-Basic Life Support for Healthcare Providers certification from an approved program. Upon Hire Required

Physical Demands

• Sit - Frequently
• Stand - Occasionally
• Walk - Occasionally
• Drive - Rarely
• Climb (Stairs/Ladders) - Rarely
• Bend (Neck) - Occasionally
• Bend (Waist) - Occasionally
• Squat - Rarely
• Twist/Turn (Neck) - Frequently
• Twist/Turn(Waist) - Occasionally
• Lift/Carry 0-10 lbs. - Rarely
• Lift/Carry 11-25 lbs. - Rarely
• Lift/Carry 26-35 lbs. - Rarely
• Lift/Carry 36-50 lbs. - Rarely
• Push/Pull up to 10 lbs. - Occasionally
• Push/Pull 11-25 lbs. - Occasionally
• Push/Pull 26-35 lbs. - Occasionally
• Push/Pull 36-50 lbs. - Occasionally
• Push/Pull 51-75 lbs. - Occasionally
• Push/Pull 76-100 lbs. - Rarely
• Reach (Above shoulder level) - Occasionally
• Reach (Below shoulder level) - Occasionally
• Simple Grasping (Hands/Arms) - Constantly
• Fine Manipulation (Hands/Arms) - Constantly
• Gross Manipulation (Hands/Arms) - Frequently

Working Conditions

• Noise - Occasionally

Travel Requirements

• 5%

Hearing Requirements

• Hears Whispers < 3 feet - Constantly
• Hears Whispers 3-8 feet - Constantly

Vision Requirements

• Color Discrimination - Constantly
• Near Vision (Correctable to Jaeger 2 or 20/40 binocular) - Constantly
• Distance Vision (Correctable to Snellen chart 20/40 binocular) - Constantly

Prevea is an Equal Employment Opportunity/Affirmative Action employer. In compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United State and to complete the required employment eligibility document form upon hire. Prevea participates in E-verify. To learn more about E-Verify, including your rights and responsibilities, please visit www.dhs.gov/E-Verify