Clinical Responsibilities:
- Provide direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care.
- Assess, plan, implement and educate patient/family on medical and psychiatric issues.
- Maintain accurate and continued nursing documentation including patient histories, conditions, treatments, responses
- Identify and address psychosocial, cultural, ethnic and religious/spiritual needs of patients and family.
- Responds to consumers’ requests for medication refills. Reviews charts for treatment compliance.
- Administers medication observing the seven rights of medication administration and ordering of medications to the pharmacy
- Administers medical and psychiatric screening instruments as appropriate
- Performs venipuncture for laboratory requests, drug screens, TB skin tests, etc.. monitors lab results and reports all abnormal findings to the physician
- Provides individual, family and group education regarding consumer’s psychiatric illness.
- Provides medication education for the consumer and family, including uses and potential side effects. Monitors consumers for potential side effects of medications and reports findings to the physician/CRNP/RN.
- Communicates effectively with the physician regarding the consumer’s physical and mental condition.
- Follows up on missed injections and documents in consumers record appropriately
- Completes admission procedures for consumers and updates accordingly to AltaPointe’s Policy and Procedures. This process includes at a minimum: medical checklist, AIMS, vital signs, Medication List, and MARS if applicable
- Documents on, updates, and reconciles MARS if applicable
- Interacts with consumer and evaluates needs to ensure that proper in formation is reported during staffing with the treatment team
- May conduct infection control training for staff and consumers when indicated
- May provide HIV education
- Interfaces with the multi-disciplinary team and actively and cooperatively participates in development of the interdisciplinary treatment plan.
- Provides emergency care as needed (CPR, PMAB, Emergency Medications), according to AltaPointe/Accordia Policy & Procedures.
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation.
- Adheres to professional code of ethics.
- Effectively demonstrates the application of adult specific competencies.
- Performs related duties as assigned
- Meets Accordia Health productivity standards
- Participates in general and medical staff meetings as required
Supervision and Consultation:
- Seeks clinical supervision and consultation needs.
- Accepts and employs suggestions for improvement.
- Actively works to enhance clinical skills.
Clinical Record Keeping:
- Documents in a timely fashion per AltaPointe policy.
- Documents in a clear, concise manner, types of consumer problems, treatment goals and services provided.
- Documentation shows that forms, notes, logs, and other applicable written information are completed promptly, accurately and updated when appropriate.
- Documents legibly.
- Meets AltaPointe productivity standard
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