Registered Nurse (RN) Staff Nurse

Purpose :

To assure quality nursing care for patient by following physician's orders, state and federal regulations and this Facility's policies and procedures.

Essential Job Functions and Requirements :

• Makes walking rounds at the beginning and end of shift while receiving and / or giving report
• Counts narcotics at beginning and end of shift, always initialing the count sheet appropriately ascertaining accuracy of count
• Performs fingersticks as ordered by MD scheduled during shift
• Administers all medications (oral, s.q., I.M., or I.V.) as ordered by M.D. and according to contracted Facility policies.
• May administer up to 60 minutes before or after time ordered. Also, administers (hangs) tube feeding as ordered by M.D.;

starts I.V.'s as ordered

• Checks critical or "sick" patients frequently and documents findings, changes, etc. in Nurses Notes and notifies supervisor and / or M.D. as necessary
• Observes patients for symptoms and / or reactions, including general physical and / or mental condition for signs which may be indicative of adverse change.

Reports these to supervisor and / or MD as necessary. Documents in nurses notes and places on charting list and calendar.

Also notifies patient's family as necessary of any significant change in patient's condition

• Leads, guides, and supervises facility nursing assistants and orderlies
• Supervises care and treatments performed by facility nursing assistants and orderlies. (Example : Vital signs, ROM, ambulation, rehabilitative programs, etc.

Monitors documentation of care and treatments performed by nursing assistants and orderlies

• Completes incident reports and calls physician if needed
• Completes appropriate nursing documentation according to facility policies and procedures.
• Admits new patients, completing the following : Nurses Admission Record, Nurses Notes, status change slip, dietary requisition, taking off orders, and checking MAR's
• Transfers and / or discharges patients when ordered by physician
• Assists physicians with rounds as needed
• Drapes, remains with and cares for patients during MD rounds, physical examinations, and treatments as necessary
• Notifies MD of any error administering medication should such occur
• Documents PRN medications and also the effectiveness or lack of effectiveness appropriately on PRN sheet
• Performs treatments scheduled during shift and documents appropriately
• Monitors specific skin tears and / or other skin conditions' and documents at least weekly or more often if warranted
30+ days ago