APP STUDENT CLINICALS APPLICATION

Transcription

1 APP STUDENT CLINICALS APPLICATION Thank you for your interest in performing clinicals at Stillwater Medical Center. Please read the following eligibility and requirements before completing the application. CRITERIA TO PARTICATE: 1. Must be enrolled in an Advanced Practice Provider program. 2. Applications will not be accepted in August. 3. Submit a complete application along with a photocopy of your immunizations for verification to: Human Resources Stillwater Medical Center 1606 W. 7 th Avenue Stillwater, OK appclinicalrequest@stillwater-medical.org Phone: Fax: You will not be scheduled without a complete application. 5. Please understand that, depending on numerous factors including patient and student volumes, placement is not guaranteed. 6. You will be notified regarding the status of your application within one to two weeks of submitting it. 7. If accepted, we will set-up an appointment time for you to pick-up your badge. We schedule appointments for processing on Tuesdays.

2 We are dedicated to protecting you and our patients from infectious disease. The chart below must be filled out for the listed vaccinations. Also, documentation of the following immunizations is required to begin your shadowing/ observation experience. A photocopy of your immunizations record must be attached to this form as proof of immunization. REQUIRED IMMUNIZATIONS Date of Vaccination (m/d/yyyy) Clinic or physician s office where vaccinated 2 MMR vaccinations or laboratory confirmation (titer) of disease of immunity. First Vaccination Date Second Vaccination Date TB Dates of 2 negative TB skin tests completed within the past 12 months. If positive, date of Chest X-Ray and clearance. Hepatitis B dates of 3 Hep B or waiver 2 Varicella vaccinations, or written documentation of disease (Chicken Pox) from a healthcare provider, or laboratory evidence of immunity (titer). First TB test Second TB test (must be within 30 days of shadowing) First Vaccination Date Second Vaccination Date Third Vaccination Date First Vaccination Date Second Vaccination Date Flu-If your clinicals will occur between Oct. 1 and March 31, proof of a current flu shot must accompany this application.

3 CLINICALS APPLICATION Date: Name (please print) Phone Home Address Are you a student currently enrolled in a Nurse Practitioner or Physician Assistant program Current School Does this school have a current contract with Stillwater Medical Center? Please list the Electronic Health Record systems that you have used. -Nurse Practitioner Program -Physician Assistant Program Please list the clinics/specialties, number of hours needed, and the dates needed for each specialty. Positions are limited and based on provider availability. Participating departments are: Women s Health Family Practice/Internal Medicine Emergency Medicine Orthopedics Are you a current SMC Employee? If yes to above question, are you receiving Education Assistance from SMC? What are your career goals after graduation? (Please choose one) Working outside of the state of Oklahoma Working in a large facility in OKC or Tulsa Working in a small rural community Working at Stillwater Medical Center Pursue further education and not work

4 CLINICALS DAY Badge Student will be given a SMC Student badge. DRESS CODE ACCEPTABLE/APPROPRIATE Acceptable/appropriate attire includes dress shirts, mock knit shirts, dress slacks, suits, sport coats, blazers, ties, dresses or skirts (of suitable lengths to maintain modesty), and sleeveless blouses. Appropriate undergarments must be worn at all times and should not be visible at any time. UNACCEPTABLE/INAPPROPRIATE DRESS Stained, wrinkled, tight, frayed, or revealing clothing, denim skirts and pants, denim scrubs, excessive use of jewelry, dark or colored lenses of eyeglasses unless required for health reasons, T-shirts, tank tops, tube tops, halter tops, or crop tops, form fitting clothing (i.e. leggings), sweat shirts/suits/pants overly casual (example: jersey knit) capris and gauchos, wind suits, jumpsuits, shorts, overalls, lounge wear, shirts or tops with inappropriate slogans and/or designs, hats unless required in area of work or identified as part of a uniform by department guidelines, and curlers. Shoes designed with holes (e.g. crocs, sandals, open-toed shoes) cannot be worn in patient care areas. Also prohibited is dress that reveals skin in the midriff area of the body, including abdomen and back (i.e. no clothing gap between pants/skirts and shirts/blouses). FOOTWEAR A. Footwear should be in good repair, clean or polished, comfortable, and appropriate to the job category. Parking On the day(s) of your clinicals experience, you should park in the student/overflow section located in the farthest lot East of the hospital's main entrance facing Monroe street, if clinicals take place at the hospital. Conduct Stillwater Medical Center is happy to offer assistance to students and want our participants to have a positive learning experience. Please remember that you will be a guest and will be expected to act in a courteous and respectful manner.

5 STILLWATER MEDICAL CENTER CONFIDENTIALITY and INFORMATION SECURITY Stillwater Medical Center has the responsibility to protect the confidentiality of all patient information, to ensure that the interests of the patient are protected. Throughout the student experience, the student may have access to confidential information of patients, physicians, employees and others. This information is to be respected and not discussed in any manner with other patients, employees, students or those outside the hospital. Students are not permitted to disclose any information concerning the patient's admission to the hospital, condition of the patient/patient chart information, the physician's orders, or the nursing care received by the patient to anyone other than those individuals directly involved with the patient in the admission/care/discharge process. Student also agrees never to give or release their computer password to anyone. Any infraction of this policy is considered to be poor conduct and a breach of ethics. A student found in violation of this policy will be subject to termination of the student experience. I understand and agree that in the performance of my duties as a student at Stillwater Medical Center, I must hold patient information in strict confidence, only access information I have a need to know, and not disclose any confidential information concerning patients, physicians, employees and others. Further I understand, that intentional or involuntary violation of this confidentiality statement is basis for disciplinary action and possible termination. Information Systems--Any mode of data, software application, equipment, and/or computer technology used to conduct the mission of SMC. All information systems are the property of SMC and are open to administrative review. Each student must read and understand the "Information Systems Security" policy and procedure prior to receiving access to any hospital systems. The student must also read and understand any additional policies and procedures related to the information systems for which they are being given access. It is very important that each student understand that the security of the information systems is their responsibility; including ensuring that terminal/pc access is not left unattended or unsecured. In addition, each student must understand the importance of patient confidentiality and also understand that any entry made via the system that affects patients is the very same as making an entry into the Medical Record. Your assigned password/security code is unique to you and is for your knowledge and use only. Any unauthorized use of another student or employee's password/security code, disclosure of your password/security code, or failure to maintain security of the terminal during periods of access by use of your password/security code will result in termination of your student experience at SMC. When you make an entry into the system, your initials will be recorded and your initials are as legally binding as your written signature. I have read and understand the above pages, and agree to comply with Confidentiality and Information Security Policy. Name