Clinical Responsibilities
- Provides direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care.
- Effectively document and maintain EHR health records for populations served.
- Complete assigned patient cases and orders in by next business day at 5pm.
- Assesses, plans, and educates patients/families on medical and psychiatric issues.
- Complete Worker’s Compensation and Pre-Employment Health Screens.
- Maintains accurate and continued nursing documentation including patient history, conditions, treatments, and responses.
- Identifies and addresses psychosocial, cultural, ethnic and religious/spiritual needs of patients/families.
- Responds to consumers’ requests for medication refills and 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 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 new patient and established patient workflow templates within EHR.
- Documents, 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.
- Performs related duties as assigned.
- Meets Accordia Health productivity standards.
- Participates in general and medical staff meetings as required.
- Adheres to professional code of ethics.
- Effectively demonstrates the application of population served specific competencies.
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.
Courteous and respectful towards consumers, visitors and co-workers
- Treats consumers with care, dignity and compassion.
- Respects consumer’s privacy and confidentiality.
- Is pleasant and cooperative with others.
- Assists consumers and visitors as needed.
- Personal values don’t inhibit ability to relate and care for others.
- Is sensitive to the consumer’s needs, expectations, and individual differences.
- Is gentle and calm to consumers and families.
- Works in a dependable, cooperative, and positive manner with both program and other AltaPointe staff members
Administrative and Other related duties as Assigned
- Actively participates in Performance Improvement activities.
- Actively participates in AltaPointe committees as required.
- Completes assigned tasks in a timely manner.
- Accesses appropriate community resources according to consumer needs.
- Complies with AltaPointe policies & procedures.
- Maintains current State license and requirements for renewals (i.e. CEU’s) and attends to required in-services and workshops.