OB Triage Per Diem

Assessment and Management

· Performs complete history & physicals and documents in the medical record.

· Orders and collects data using appropriate assessment techniques, relevant supporting diagnostic information and diagnostic procedures where indicated.

· The APC may serve as the first responder for both nursing and house staff in the event of patient status changes, orders, and in situations requiring procedural and resuscitative interventions.

· Assesses for risks associated with the care of the acute and complex chronically ill patient including: medication side effects, immobility, impaired nutrition, fluid and electrolyte imbalance, immunocompetence, invasive interventions and diagnostic procedures.

Diagnosis

· Obtain a comprehensive health history and physical examination (including pelvic exam), order and interpret common laboratory and diagnostic studies, and interprets electronic fetal heart rate monitoring.

· Collaborates with interdisciplinary health care team in making diagnoses of acute and complex chronic conditions.

· Manages diagnostic tests through ordering, interpretation, performance, and supervision.

· Formulates differential diagnoses by priority.

· Diagnoses complications and orders appropriate interventions

Formulates Plan of Care

· Identifies expected outcomes from diagnosis, and formulates and documents a plan of care to address complex acute and chronic health care needs.

· Utilizes evidence-based practice guidelines and protocols in an individualized, dynamic plan of care that can be applied across the continuum.

· Implements and modifies plan of care.

· Prescribes diagnostic strategies and therapeutic interventions.

· May perform advanced procedures consistent with privileges and competency validation.

Communication and Collaboration

· Maintains ongoing communication and collaboration with interdisciplinary health care team.

· Facilitates and communicates with patient, family and staff to promote continuity of care across the inpatient and outpatient continuum of care.

Documentation

· Documents/dictates key components of patient's progress via daily progress note, transfer, and discharge summary, and or clinic note where applicable. (h&p, daily progress notes, plan of care, problem lists, procedure notes, acute event note, discharge summaries, in medical record per specific patient unit or service, death summary)

· Documentation is timely, meets acute care compliance standards and captures patient acuity.

Professional Practice

· Demonstrates Professional Practice behaviors including: preceptor/mentoring, education and instruction of graduate students.

· Seeks opportunities for active engagement in research and the analysis of evidenced-based practice.

· Actively participates in Advance Practice Grand Rounds and specialty-specific meetings.

· Maintains CEUs, and membership in a professional organization

Qualifications

· CNM, PA-C, or Women’s Health CRNP

· NCC Certification in Women's Health (CRNP)

· Previous fetal monitoring and L&D experience valued but not required.