RN-Clinical Data Abstractor (H)

It's more than a career, it's a calling

MO-SSM Health Cardinal Glennon Children's Hospital

Worker Type:

Regular

Job Highlights:

Department: Surgery; Safety & Quality; Process Improvement

• Schedule:
  • 3 days per week, 8 hours per day
  • flex time as needed to meet responsibilities
• Job duties:
  • Abstract appropriate clinical information from medical records to support safety and quality of care and process improvement efforts
  • Maintain abstracted information within prescribed Excel databases.
  • Escalate and disseminate medical record review findings within the established timeframe as appropriate
  • Identify and communicate opportunities and trends.
  • Contribute data for quality improvement projects and process improvement initiatives.
  • Participate as a member of multidisciplinary QI teams.
• Desired Qualifications:
  • >3 years RN experience
  • Experience with data abstraction
  • Experience with outcome indicators
  • Experience navigating Epic

Job Summary:

Collaborates with physicians and the electronic health record (EHR) optimization team to identify what clinical information needs to be abstracted or analyzed and then abstracts the clinical information from multiple records and appropriately enters into the EHR database.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Interacts with physicians and nursing staff in the process of departmental abstraction of their patients’ medical information. Obtain required records from referring physicians and primary care providers.
• Abstracts appropriate clinical information from outside medical records and inputs into the EHR database for Best Care/Best Results.
• Reviews outside records for information vital to specific referral, focusing on medical history, surgical history, allergies and medications. Inputs abstracted data into appropriate defined areas of EHR.
• Ensures data is abstracted within established timeframes to ensure continual flow of information and increase efficiency of office visits facilitating patient entry into specialty services.
• Applies evidenced based practices to achieve multidisciplinary collaboration and to facilitate continuity of care.
• Contributes to the overall satisfaction of the department by actively participating in department functions and offering assistance to others as needed.
• Works in a constant state of alertness and safe manner.
• Performs other duties as assigned.

EDUCATION

• Graduate of accredited school of nursing or education equivalency for licensing

EXPERIENCE

• Two years' registered nurse experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS 
 
State of Work Location: Illinois 

•     Registered Professional Nurse (RN) - Illinois Dep