What are the responsibilities and job description for the Medical Records Nurse position at Yale New Haven Health?
To be a vital member of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values.
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. We value Nursing Professional Governance, and use evidence and data to support our practice with the patient and family at the center, always.
- 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 healthcare 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.
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.
- Accountable for their professional actions to themselves, their healthcare consumers, their peers and ultimately to society
- Practices in a manner that is congruent with cultural diversity and inclusion principles
- Communicates effectively in all areas of practice
- Collaborates with healthcare consumer and other key stakeholders in the conduct of nursing practice
- Solicits feedback from others and acts on it
- Evaluates own's and others' nursing practice
- Utilizes appropriate resources to plan provide and sustain evidence-based nursing services that are safe, effective and fiscally responsible
- Practices in an environmentally safe and healthy manner
Graduation from an accredited School of Nursing. May be exposed to infectious diseases. Moderate stress and risk of injury from patient care. The RN must have a minimum of 2 years of critical care experience (pediatric experience preferred).
