Primary Job Functions:
Clinical Responsibilities:
- Provides direct patient care, evaluate outcomes, consult with other members of the care team as required, adjusting nursing care, if indicated.
- Provides individual and family education regarding patient’s psychiatric illness and medications, including uses and potential side effects.
- Maintains accurate and continued nursing documentation, including patient histories, conditions, treatments, and responses.
- Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and family.
- Completes the assessment process accurately and promptly for patients, including at minimum medical checklist, vital signs, medication list, AIMS when required, and any indicated screenings.
- Responds to patient phone messages, including requests for medication refills or adjustments, questions regarding treatment, or other concerns; documents these interactions promptly and accurately.
- Completes prior authorization forms in a timely manner.
- Maintains sample log and inventory according to policy and procedures.
- Administers medications, observing the seven rights of medication administration.
- Ensures injections are ordered for delivery prior to injection appointments, including SU medications.
- Monitors patients for potential side effects of medications and reports findings to the physician.
- Follows up on missed appointments and documents in patients’ records.
- Complete urine drug screens, pregnancy tests, and breathalyzer tests as needed for SU appointments, informing treatment team of results.
- Communicates effectively with the physician regarding the patient’s physical and mental condition.
- Interfaces actively and cooperatively with a multi-disciplinary team to assist in the 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 AltaPointe Policy & Procedures.
- Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation.
- Effectively demonstrates the application of nursing competencies.
- When necessary, provides nursing coverage to other adult outpatient programs within Baldwin County.
- 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 AltaPointe policy.
- Documents in a clear, concise manner regarding types of patient problems, treatment goals, and services provided
- Completes all required forms, logs, notes and other applicable documentation promptly and accurately.
- Writes legibly on handwritten documents.
- Meets AltaPointe productivity standards.
Courteous and Respectful Attitudes Towards Patients, Visitors and Coworkers:
- Treats patients with care, dignity, and compassion.
- Respects patient’s privacy and confidentiality through knowledge of and strict abidance to HIPAA standards.
- Is pleasant and cooperative with others.
- Assists patients and visitors as needed.
- Does not allow personal values to inhibit the ability to relate to and care for others.
- Is sensitive to the patient’s needs, expectations, and individual differences.
- Is gentle and calm to patients and families.
- Works in a dependable, cooperative, and positive manner with program and AltaPointe staff members.
Administrative and Other Related Duties as Assigned:
- Actively participates in Performance Improvement activities.
- Actively participates in AltaPointe committees, when required.
- Completes assigned tasks in a timely manner.
- Accesses appropriate community resources according to patient needs.
- Follows AltaPointe Policy & Procedures.
- Maintains current state license and requirements for renewals (i.e., CEUs).
- Attends to required in-services and workshops.
- Other duties as assigned.
Physical Requirements of the Job:
- There is frequent standing while getting files, paperwork, and handing out medication.
- Sitting is frequent by nature and up to 5-10 minutes; however, extended sitting could be up to 1.5 to 3 hours for documentation.
- Squatting and/or lunging frequently to stock supplies and retrieve needed material from file cabinets and bookshelves.
- Fine manipulation for writing, handling paperwork, and dispensing medications to patients.
- Pushing and/or pulling force up to 1-5 pounds force, horizontally, to open file cabinets and place binders on bookshelves.
- Lifting various ranges from the floor to overhead with weights up to 1-5 pounds frequently.
- Any other duties as assigned by supervisor.