Job description

Job responsibilities

Accurately transcribe medical correspondence from digital dictation and other approved sources.

Type outpatient clinic letters, consultation letters, operative notes, procedure reports, discharge summaries and other clinical correspondence.

Ensure documentation is accurately formatted and presented in accordance with Tyneside Surgical Services standards.

Check spelling, grammar, punctuation and medical terminology.

Ensure patient names, dates of birth, NHS numbers and other identifying information are accurately recorded.

Identify obvious discrepancies or omissions within dictated correspondence and refer these to the appropriate clinician or manager.

Ensure correspondence is completed and returned within agreed departmental timescales.

Amend and retype correspondence when requested by clinicians.

Maintain accurate electronic and or paper records in accordance with local procedures.

Person Specification

Experience

Essential

• Previous medical typing/medical administration experience
• Excellent typing skills and accuracy
• Knowledge of medical terminology
• Excellent written English
• Good spelling, grammar and punctuation
• High level of attention to detail
• Ability to work to deadlines
• Ability to maintain confidentiality
• Experience using electronic patient record systems
• IT literate and confident using Microsoft Office

Desirable

• Experience working within a healthcare environment
• Knowledge of NHS terminology and processes
• Experience with digital dictation/voice recognition systems
• Experience within a surgical or outpatient environment

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

Employer details

Employer name

Tyneside Surgical Services

Address

19 Fellsdyke Court

Gateshead

Tyne And Wear

NE10 9SB

United Kingdom

Employer's website

http://www.tynesidesurgicalservices.co.uk/ (Opens in a new tab)

Job description

Job responsibilities

Job Purpose

The Pre-Assessment Nurse will be responsible for delivering high-quality, patient-centred pre-operative assessment and preparation for patients undergoing surgical day case procedures and endoscopy procedures at Tyneside Surgical Services. The post holder will work closely with consultants, anaesthetic colleagues, theatre staff, administrative teams and other healthcare professionals to ensure patients are appropriately assessed, optimised and prepared for surgery.

The role will contribute to the safe and efficient patient pathway from referral through to admission, ensuring relevant clinical information is identified, documented and escalated appropriately.

Undertake comprehensive pre-operative and endoscopy nursing assessments in accordance with local policies, procedures and agreed clinical pathways.

Review patients' medical, surgical and medication history, including allergies, previous anaesthetic history and relevant comorbidities.

Identify potential clinical risks that may affect suitability for surgery or anaesthesia and escalate concerns appropriately.

Assess patients' physical, psychological and social needs in preparation for surgery and endoscopy procedures

Dispense bowel preparation in accordance with Patient Group Directions (PGDs)

Ensure appropriate investigations, observations, screening and clinical information are available and reviewed in accordance with the patient's procedure and pathway.

Identify patients requiring further clinical review, optimisation, additional investigations or anaesthetic assessment.

Liaise with consultants, anaesthetists, GPs, specialist teams and other healthcare professionals where required.

Provide patients with clear information regarding their procedure, preparation, fasting, medication management, admission and discharge arrangements, within the nurse's scope of practice.

Support patients to understand their individual care pathway and provide appropriate health education and advice.

Ensure accurate, contemporaneous and confidential documentation within the patient record.

Undertake and document appropriate observations and clinical assessments.

Contribute to safe discharge planning and identify any post-operative support requirements where relevant.

Maintain effective communication with the wider multidisciplinary team to support a safe and efficient patient journey.

Participate in clinical audits, quality improvement, governance activities and service development.

Comply with infection prevention and control requirements and maintain high standards of cleanliness and aseptic practice where applicable.

Maintain knowledge of current clinical guidance and relevant professional standards.

Work within the Nursing and Midwifery Council Code and the individual's professional scope of practice.

Undertake any other reasonable duties consistent with the level and responsibilities of the role.

Complete a structured nursing pre-assessment using the organisation's approved assessment documentation.

Assess baseline observations and identify abnormal findings requiring further review.

Review relevant medical history and identify significant comorbidities or risk factors.

Review prescribed, over-the-counter and relevant complementary medications and identify issues requiring clarification.

Check allergies and adverse drug reactions.

Review relevant previous investigations, clinical correspondence and results available to the service.

Identify potential issues relating to mobility, nutrition, frailty, cognition, communication or social circumstances where relevant.

Identify infection risks and ensure appropriate screening or escalation in accordance with local policy.

Recognise when a patient may require additional specialist assessment or optimisation before proceeding.

Communicate clearly with the patient and document the outcome of the assessment.

Provide a welcoming, respectful and professional service to every patient.

Communicate complex clinical information in a clear and understandable manner.

Ensure patients have an opportunity to ask questions and raise concerns.

Adapt communication to individual needs, including language, hearing, cognitive or communication difficulties.

Maintain patient dignity, privacy and confidentiality at all times.

Support patients who may be anxious or apprehensive about surgery.

Maintain professional registration and comply with the NMC Code.

Maintain mandatory and role-specific training requirements.

Work within agreed policies, procedures, protocols and scope of practice.

Maintain accurate clinical records and comply with information governance and confidentiality requirements.

Report incidents, near misses, safeguarding concerns and clinical risks in accordance with organisational procedures.

Participate in audit, reflective practice, supervision, appraisal and continuing professional development.

Contribute positively to the development of a culture of safety, openness, learning and continuous improvement.

Person Specification

Experience

Essential

• Post-Registration nursing experience preferably including surgical, peri-operative, medical or pre assessment nursing.

Desirable

• Experience in an independent healthcare/day-case environment.
• Formal pre-operative assessment experience
• Experience providing patient education

Qualifications

Essential

• Current NMC registration as a Registered Nurse
• Qualified in Phlebotomy
• Qualified in Cannulation
• Clinical Skills Course
• ECG interpretation skills

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Tyneside Surgical Services

Address

Tyneside Surgical Services

Independent House

Fifth Avenue

Gateshead

Tyne And Wear

NE11 0HF

United Kingdom

Employer's website

http://www.tynesidesurgicalservices.co.uk/ (Opens in a new tab)