Render professional nursing care to patients within the treatment programs. Practice ongoing patient assessment, evaluation and update of patient care through observation of physical and behavioral symptoms and communicates pertinent data to other service areas as needed. Administer medications appropriately and document all data accurately according to facility policy. Participate in formulation of individual treatment plans for all patients and implements plan according to facility policy.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Conduct admissions in compliance with applicable standards, regulations and hospital protocol.
Accurately record all sick calls, tardiness, cancellations and absences of staff during shift.
Assume responsibility for adequate staffing coverage, not only for assigned shift, but also for the upcoming shift, staying within FTE standards.
Supervise and assign areas of responsibility for LPNs, CNAs, and MHAs and during shift.
Collect and analyze data regarding the patient's physical, psychosocial, environmental, self-care, educational, and anticipated discharge planning needs.
Determine patients' alcohol or drug toxicity and identify signs of withdrawal.
Develop a comprehensive outline of care and specific goals and interventions to be included in treatment planning.
Monitor patients following nursing unit policies and procedures.
Communicate changes in patient's status (legal, psychiatric, physical) with attending physician.
Inform incoming shift of any changes or problems with patients to promote continuity of care.
Participate in hospital emergency codes necessary to the unit's and the hospital's safe operation.
Review patient records for accuracy and ensure that treatment plan and progress notes clearly reflect progress of patient and family.
Comply with safety and security policies and procedures, including those regarding incidents and injuries.
Manage medication of patients by ensuring physician orders are implemented, evaluated and documented and by assuring proper administration of medication to each patient.Report any dosages or physician's orders in question to the Nursing Supervisor.
Observe and report the patient's signs, symptoms, and behaviors and any subsequent treatment and/or interventions and records same in the medical record according to facility policy.
Formulate, implement and evaluate treatment plans.Update treatment plan as necessary.
Participate in treatment planning and contributes pertinent observations and knowledge of updating and changes of the treatment plan.
Assess the behavioral and medical needs of patients each shift.
Provide individual instruction to patients and their families concerning medications, health, and medical needs.
Participate in and/or supervises and documents special treatment procedures, progressive interventions and de-escalation of patients according to facility policy.
Consistently meet facility and regulatory training requirements by attending all mandatory staff meetings and training sessions as required.
Assure cleanliness and orderliness of the assigned area and proactively assist in all security, maintenance, and safety functions as required for the overall facility to help maintain the physical environment to assure the safety of patients and staff.
Ensure compliance with all company policies, procedures, and other regulatory requirements by reporting any known or suspected violations to the supervisor or through other means identified in company policy.Maintain confidentiality of all patient records per program guidelines.
Provide timely, accurate, and professional documentation according to facility policy.
Participate in, and supports, performance improvement initiatives.
Project a positive role model image for patients and colleagues by participating as a team member, cooperating with staff, demonstrating compromise and appropriate expression of opinions, and attending staff meetings as required.
Maintain appropriate relationships with patients by treating them in a respectful manner at all times, by eliciting patients' interest and cooperation, and by maintaining appropriate boundaries.
Ensure the right of all patients are observed and protected through the use of appropriate and respectful communication, proper de-escalation techniques, and correct physical restraint methods when necessary.
Will adhere to all safety policies and safe work practice.
Will adhere to all hospital policies and procedures.
Perform other duties as assigned.
Support facility internal and external customer service standards.