What are the responsibilities and job description for the Medical Records Nurse position at Yale New Haven Health?
About Our Organization
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values.
The Role of the Registered Professional Nurse (RN)
As an integral member of the Yale New Haven Health System (YNHHS) healthcare team, the Registered Professional Nurse (RN) upholds the YNHHS mission, vision, values and strategic initiatives to provide the highest level of patient centered care.
Nursing Practice
The RN practices professional nursing as a registered nurse within the legal and ethical framework established by the Connecticut Nurse Practice Act, American Nurses Association Scope and Standards for Nursing Practice, ANA Code of Ethics for Nurses and the YNHHS Professional Practice Model. The professional role of the RN is exemplified by the qualities of leadership, delegation, collaboration, effective communication, ensuring quality outcomes.
Evaluation of Care
We value Nursing Professional Governance, and use evidence and data to support our practice with the patient and family at the center, always. The RN provides care that:
Standards of Practice
The Standards of Practice describe a competent level of nursing care as demonstrated by utilizing the nursing process components of assessment, diagnosis, outcomes identification, planning, implementation and evaluation.
Nursing Process
Assessment: The registered nurse collects pertinent data and information relative to the healthcare consumer's health or situation
Diagnosis: The RN analyzes the assessment data to determine the actual and potential diagnoses or the issues
Outcomes Identification: The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation
Planning: The RN develops and modifies a plan of care that prescribes strategies and alternatives to attain expected outcomes
Implementation: The RN implements the identified plan
Coordination of Care: The RN coordinates care delivery and transitions in care
Health Teaching and Health Promotion: The RN employs strategies to promote health and a safe environment
Standards of Professional Performance
The ANA Standards of Professional Performance (2015) describe a competent level of behavior in the professional role, including activities related to ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, quality of practice professional practice evaluation, resource utilization and environmental health. The RN is accountable to themselves, their healthcare consumers, their peers and ultimately to society. The RN practices in a manner that is congruent with cultural diversity and inclusion principles.
Accountability and Practice Principles
The RN communicates effectively in all areas of practice Collaboration: The RN collaborates with healthcare consumer and other key stakeholders in the conduct of nursing practice. Education: The RN seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Evidence-Based Practice and Research: The RN integrates evidence and research findings into practice Quality of Practice: The RN contributes to quality nursing practice. Professional Practice Evaluation: The RN evaluates owns' and others' nursing practice. Resource Utilization: The RN utilizes appropriate resources to plan provide and sustain evidence-based nursing services that are safe, effective and fiscally responsible Environmental Health: The RN practices in an environmentally safe and healthy manner.
Qualifications
Graduation from an accredited school of nursing. May be exposed to infectious diseases. Moderate stress and risk of injury from patient care. New grads welcome to apply.
To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values.
The Role of the Registered Professional Nurse (RN)
As an integral member of the Yale New Haven Health System (YNHHS) healthcare team, the Registered Professional Nurse (RN) upholds the YNHHS mission, vision, values and strategic initiatives to provide the highest level of patient centered care.
Nursing Practice
The RN practices professional nursing as a registered nurse within the legal and ethical framework established by the Connecticut Nurse Practice Act, American Nurses Association Scope and Standards for Nursing Practice, ANA Code of Ethics for Nurses and the YNHHS Professional Practice Model. The professional role of the RN is exemplified by the qualities of leadership, delegation, collaboration, effective communication, ensuring quality outcomes.
Evaluation of Care
We value Nursing Professional Governance, and use evidence and data to support our practice with the patient and family at the center, always. The RN provides care that:
- Establishes and maintains a therapeutic relationship with the patient and family
- Encompasses an understanding and integration of cultural and diversity into practice
- Includes communicating and working collaboratively with the patient, family and health care team members
- Includes respecting the patient's values, preferences, expressed needs and knowledge of the healthcare situation in holistic data collection, in formulating health care outcomes and in the evaluation process.
Standards of Practice
The Standards of Practice describe a competent level of nursing care as demonstrated by utilizing the nursing process components of assessment, diagnosis, outcomes identification, planning, implementation and evaluation.
Nursing Process
Assessment: The registered nurse collects pertinent data and information relative to the healthcare consumer's health or situation
Diagnosis: The RN analyzes the assessment data to determine the actual and potential diagnoses or the issues
Outcomes Identification: The RN identifies expected outcomes for a plan individualized to the healthcare consumer or the situation
Planning: The RN develops and modifies a plan of care that prescribes strategies and alternatives to attain expected outcomes
Implementation: The RN implements the identified plan
Coordination of Care: The RN coordinates care delivery and transitions in care
Health Teaching and Health Promotion: The RN employs strategies to promote health and a safe environment
Standards of Professional Performance
The ANA Standards of Professional Performance (2015) describe a competent level of behavior in the professional role, including activities related to ethics, culturally congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, quality of practice professional practice evaluation, resource utilization and environmental health. The RN is accountable to themselves, their healthcare consumers, their peers and ultimately to society. The RN practices in a manner that is congruent with cultural diversity and inclusion principles.
Accountability and Practice Principles
The RN communicates effectively in all areas of practice Collaboration: The RN collaborates with healthcare consumer and other key stakeholders in the conduct of nursing practice. Education: The RN seeks knowledge and competence that reflects current nursing practice and promotes futuristic thinking. Evidence-Based Practice and Research: The RN integrates evidence and research findings into practice Quality of Practice: The RN contributes to quality nursing practice. Professional Practice Evaluation: The RN evaluates owns' and others' nursing practice. Resource Utilization: The RN utilizes appropriate resources to plan provide and sustain evidence-based nursing services that are safe, effective and fiscally responsible Environmental Health: The RN practices in an environmentally safe and healthy manner.
Qualifications
Graduation from an accredited school of nursing. May be exposed to infectious diseases. Moderate stress and risk of injury from patient care. New grads welcome to apply.
