Clinical Responsibilities:
- Assists with the completion of the assessment process for patients including but not limited to the following: medical checklist/physical health/nursing screening, medication list/reconciliation, depression screening, height/weight and vital signs as applicable
- Administers medications, observing the Seven Rights of medication administration
- Provides education regarding patient’s disease process
- Provides medication education for the consumer and family, including uses and potential side effects
- Monitors patients for potential side effects of medications and reports findings to the physician
- Provide direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care
- Accurately assign triage categories
- Maintain accurate and continued nursing documentation including patient histories, conditions, treatments, responses, pain management and assessment of changes
- Identify and address psychosocial, cultural, ethnic and religious/spiritual needs of patients and family
- Communicates effectively with the physician regarding the patient’s physical and mental condition
- Administers medical and psychiatric screenings as needed ( PHQ-2, UNCOPE, etc.)
- Completes medical checklist, AIMS, vital signs, infoscriber as indicated
- Perform ancillary testing and tasks as ordered by presiding physician (i.e. PFT, EKG, injections, audiograms, x-ray, etc.) or calls medical facility or department to schedule patient for tests
- Gives injections or treatments and performs routine laboratory tests
- Supervises nursing functions at the site including immediate supervision of medical assistants to assure conformance with established standards and procedural requirements
- Assists patients with the assistance programs and referrals; maintains updated file of referrals and provides referral information
- Responds to consumers’ request for medication refills
- Assist with meeting reporting requirements of SAMHSA grant
- Reviews chart for treatment compliance
- Follows up on missed injections and document in chart
- Interfaces with the multi-disciplinary team and actively and cooperatively participates in development of the interdisciplinary treatment plan
- Monitors laboratory results and reports all abnormal findings to the physician
- Provides emergency care as needed (CPR, MindSet, PRN medications), according to the Accordia Health Policy and Procedures
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
- Participates in general and medical staff meetings as required
- Keys data into computer to maintain office and patient records
- Educate the community and patients on health issues to increase health literacy
- May conduct infection control for staff and consumers when indicated
- Performs related duties as assigned
- Meets AltaPointe Health productivity standards
- Effectively demonstrates the application of nursing competencies
- Adheres to professional code of ethics
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 Accordia Health policy
- Documents in a clear, concise manner, types of patient 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
Courteous and respectful attitudes towards consumers, visitors and co-workers
- Treats patients with care, dignity and compassion
- Respects patient’s privacy and confidentiality
- Is pleasant and cooperative with others
- Assists patients and visitors as needed
- Personal values don’t inhibit ability to relate and care for others
- Is sensitive to the patient’s needs, expectations and individual differences
- Is gentle and calm to patients and families
Administrative and Other related duties as Assigned:
- Actively participates in Performance Improvement activities
- Actively participates in Accordia Health committees as required
- Completes assigned tasks in a timely manner
- Accesses appropriate community resources according to consumer needs
- Follows Accordia Health Policy & Procedures
- Maintains current State license and requirements for renewals (i.e. CEU’s), and attends to required in-services and workshops