Registered Nurse Pre Admission Chart

Job Requirements

• 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...

Qualifications

Strong clinical knowledge, attention to detail, and the ability to collaborate with interdisciplinary teams to optimize patient outcomes.