Clinical Data Abstractor - Admin - Heart Center (1.0 FTE, Days)
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1.0 FTE, 8 Hour Day Shift
At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That's why we combine advanced technologies and breakthrough discoveries with family-centered care. It's why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children's Hospital Stanford. And it's why we need caring, committed people on our team - like you. Join us on our mission to heal humanity, one child and family at a time.
This paragraph summarizes the general nature, level and purpose of the job.
The Clinical Data Abstractor analyzes clinical documentation and abstracts clinical data used to capture patient health statuses, assessment of quality of care, health data comparison between providers and organizations, and/or to meet regulatory standards using prescribed protocols and entering into appropriate database systems.
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.
• Collaborates with leadership and stakeholders across the organization to transform data and information into knowledge that will assist leaders in making informed decisions that support strategic initiatives.
• Works with stakeholders and staff to improve documentation issues/discrepancies and provide feedback on documentation.
• Reviews pediatric and congenital heart center patients' records and performs patient rounds for inclusion in clinical patient data registries as identified by the facility, such as STS/ PC4/ PAC3/ IMPACT.
• Collects preoperative, intraoperative, inpatient and postoperative follow-up data components for the program through the effective utilization of the hospital medical record systems.
• Leverages data abstraction and registries to drive quality improvement efforts and reduce variation.
• Responsible for the accurate, complete, and timely entry of data into the program's database.
• Identifies streamlining and process improvement opportunities in the data collection process.
• Serves as an educational resource on the congenital heart surgery registry for internal and external audiences as needed.
• Participates in data compilation for audits and (re)accreditation or site visits.
• Communicates clearly any data documentation needs to support accurate and high reliable data collection and reporting.
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: Bachelor's Degree in Nursing from an accredited college or university.
Experience: Three (3) years of progressively responsible and directly related work experience.
License/Certification: CA Registered Nurse (RN)
Knowledge, Skills, & Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
• Knowledge of pediatric cardiology and the field's terminology.
• Ability to apply a professional nursing code of ethics and professional guidelines to clinical practice.
• Ability to be a resource for all employees assigned area of specialization.
• Knowledge of computer systems and software used in functional area.
• Knowledge of current theories, principles, practices, standards, emerging technologies, techniques and approaches in the nursing profession, and the health care system.
• Knowledge of laws, rules and regulations; standards and guidelines of certifying and accrediting bodies; hospital and department/unit standards, protocols, policies and procedures governing the provision of nursing care in the area of assignment.
• Knowledge of medical and professional nursing ethics and patient privacy rights.
Physical Requirements and Working Conditions
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Equal Opportunity Employer