Nurse Practitioner - Pre Admission Testing

1. Identifies self properly to patient and family, clarifies role of Nurse Practitioner if necessary.

2. Reports patient condition to appropriate personnel.

3. States purpose of history and physical for accurate hospital records.

4. Obtains accurate medical history including chief complaint, history of present illness, past medical/history, family history, social history and complete review of systems.
5. Evaluates the patient’s history and physical per core measure compliance.

6. Performs a Physical assessment focusing on vital signs, HEENT, cardiac, pulmonary, GI, GU, neurological and extremities.

7. Documents findings noting pertinent normal and abnormal findings according to standards.

8. Performs and documents Pre-Anesthesia Interview and home med list per policy and procedure.

9. Addresses patient’s concerns including providing comfort and support for pre-operative patients by demonstrating sensitivity to patient care and privacy.

10. Answers patient’s questions regarding pre-operative care, understanding of surgical procedures and regarding post-operative care.

11. Uses knowledge and skills necessary to provide care appropriate to the age of patient.

12. Assesses the patient for change in status and institutes appropriate interventions. Initiates necessary emergency interventions to stabilize the patient.

13. Timely dictation of the history and physical examination performed in the Pre Admission Testing area or Ambulatory Care Center to insure its availability the day of surgery.

14. Performs and participates in quality/performance improvement activities and clinical research.

15. Serves as a clinical expert and leadership consultant to nursing and members of the healthcare team.

16. Participates in and supports accreditation, compliance and regulatory activities of the organization.

17. Participates in the orientation/preceptor process of new staff members when requested and completes documentation.

18. Utilizes critical thinking skills with a clear understanding of systems and change process.

Review of Surgery/Procedure Charts

1. Reviews all preoperative/pre procedure charts to ensure completeness prior to day of surgery/procedure.
2. Accesses medical history to determine additional documentation or testing necessary prior to surgery/procedure.
3. Reviews and follows Anesthesia guidelines for all charts.
4. Communicates with office staff and physicians regarding incomplete records and abnormal results to prevent surgical delay or cancellation of procedure.

Phlebotomy and EKG

1. Correctly identifies patient, enters orders and draws lab work in Pre Admission Testing as needed, to assist nursing and phlebotomy staff.

2. Correctly identifies patient, enters orders and performs EKG in Pre Admission Testing as needed, to assist nursing staff.

3. Has all abnormal EKG’s reviewed by Anesthesia the day of Pre Admission Testing to ensure timely management.