Documentation-Rev Capture Spec Internal

Job Summary / Purpose

• Assesses and evaluates clinical documentation related systems and activities within the scope of Surgical Services at assigned site(s).

• The Operating Room of Surgery provides intraoperative care to surgical and procedural sedation patients. We provide service for the patient population of pediatrics, adolescents, adult and elderly patients. We work with a variety of provider specialties in caring for people going home that day or are being admitted to the hospital.

• Current unencumbered Oregon RN license required. BSN preferred.
• Five (5) years clinical experience in Perioperative nursing required. Experience in OR preferred.
• Experience with design, implementation of systems and project management required.
• Epic OpTime Proficiency preferred.
• Clinical leadership experience preferred.
• Experience in auditing Surgical Services records for completeness, and familiarity with the Perioperative continuum of care strongly preferred.

• Ability to navigate and proficiently use/manipulate electronic databases and office automation software. Working knowledge of EMR documentation systems.
• Excellent analytical skills to perform analysis and provide recommendations on charge capture and documentation in Surgical Services. Ability to be consistently accurate, with attention to details.
• Strong teamwork and positive communication skills. Strong meeting facilitation and group process skills. Ability to collaborate with staff and leadership to implement change.
• Knowledge of and ability to apply adult learning, CQI and Lean principles.
• Ability to work efficiently with minimal supervision, exercising independent judgment. Ability to withstand varying job pressures and organize and prioritize related tasks effectively. Ability to work with credibility and effectiveness with medical and administrative staff.

• Rarely
  (1 - 10% of the time)

  Occasionally
  (11 - 33% of the time)

  Frequently
  (34 - 66% of the time)

  Continually
  (67 – 100% of the time)

  CLIMB - LADDER

  LIFT (Overhead: 54" and above) 0 - 20 Lbs

  KNEEL (on knees)

  CRAWL (hands & knees)

  SQUAT Static (hold >30 sec)

  SQUAT Repetitive

  STAND

  CLIMB - STAIRS

  WALK - INCLINE

  LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs

  LIFT (Knee to chest: 24"-54") 0 – 20 Lbs

  LIFT (Waist to Eye: up to 54") 0 - 20 Lbs

  ROTATE TRUNK Standing

  REACH - Upward

  CARRY 1-handed, 0 - 20 pounds

  PUSH (40-60 pounds force)

  REACH – Forward

  PINCH Fingers

  GRASP Hand/Fist

  MANUAL DEXTERITY Hands/wrists

  FINGER DEXTERITY