Job Type
Full-time
Description
Job Summary : Responsible for providing professional nursing care for patients including assessment, treatment, care planning, and medical care evaluation by following established standards and practices.
Assists physicians and staff in coordinating patient care. Functions as primary liaison between patients, staff and physicians.
Primary Job Responsibilities / Tasks :
Obtains patient consent for care and ensures patient confidentiality. Obtains and documents health history, information on chief complaint, vital signs, and health risk factors and assesses disease condition.
Provides patient care based on practice guidelines, standards of care, and federal / state laws and regulations.
- Executes prescribed treatments and medical interventions, administers prescribed medications, and monitors and documents treatment progress and patient response.
- Delegates as allowed under the Nurse Practice Act. Refers to / consults with physicians, other health providers, and community resources to prevent / resolve problems or concerns.
Educates patients and families about health status, health maintenance, and management of acute and chronic conditions.
- Documents patient assessment and intervention data using established medical record forms / automated systems and documentation practices.
- Participates in multidisciplinary teams to improve patient care processes and outcomes. Tracks quality assurance data and monitors for acute and chronic care management.
- Maintains / reviews patient records, charts and other pertinent information. Posts tests and examination results.
- Responds to / refers incoming patient treatment-related phone calls.
- Maintains patient confidentiality.
Requirements
Education : RN degree. Completion of nursing training from an accredited school of nursing. BSN preferred.
Experience : Minimum of one year professional nursing experience, clinic experience preferred.
Other Requirements : Current state registered nurse license. Current CPR certificate.
Performance Requirements :
Knowledge :
- Knowledge of professional nursing theory, regulations and practices to give and evaluate patient care.
- Knowledge of nursing processes; health care systems, structure, and functions; and community resources. Understanding of health care technology, equipment, and supplies.
Familiarity with state law on nursing care, nurse practice guidelines, and clinic policies and procedures.
- Knowledge of chart / medical record documentation requirements and federal / state laws related to release of health care information.
- Knowledge of common safety hazards and precautions to establish / maintain a safe work environment.
Skills :
- Skill in applying and modifying the principles, methods and techniques of professional nursing to provide ongoing patient care.
- Skill in time management, problem solving, multitasking, prioritizing, and medical care coordination.
- Skill in initiating appropriate crisis interventions and emergency response.
- Skill in patient triage in person and on the phone.
- Skill in preparing / maintaining records, writing reports and responding to correspondence.
Abilities :
- Ability to analyze options and then counsel patients and families about choices and make referrals to other providers and resources.
- Ability to engage clients and families in the development and implementation of a care plan.
- Ability to read and interpret physicians' orders and notes from other providers.
- Ability to calculate and administer drug dosages and injections and measure results.
- Ability to maintain quality control standards.
- Ability to react calmly and effectively in emergency situations.
- Ability to communicate clearly.
Equipment Operated : Standard nursing equipment and supplies including thermometer and syringes. May involve use of assistive devices such as walkers, wheelchairs, ventilators, pulse oximetry units, and oxygen tanks.
May require use of computer.
Work Environment : Varied activities including standing, walking, reaching, bending, lifting. Requires full range of body motion including handling and lifting patient's manual and finger dexterity and eye-hand coordination.
Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 100 pounds.
Requires corrected vision and hearing to normal range. Requires working under stressful conditions or working irregular hours.