1. Assume the charge nurse role if applicable by:
- Receiving and giving accurate and thorough shift reports
- Keeping the physicians informed of patients conditions, change of conditions, LOC and triage information and needs
- Correctly entering and taking off physician orders
- Oversight of the care of patients by auxiliary personnel
- Organizing and delegating patient care activities
- Monitoring and/or performing diagnostic screening tests as ordered by physician
- Providing thorough and accurate patient information during shift exchange for end of shift report
2. Assess individual patient care needs, initiate medical treatment plan and competently implement/instruct all care in the appropriate nursing practice to all staff.
3. Serve as a resource to treatment team members.
4. Perform nursing assessments, LOC, and review patient histories to document all necessary information in the Electronic Medical Record on all patients admitted to the facility.
5. Prepare patients for examinations: height/weight, vitals, collect and process lab specimens including UDS, UA, Chem Sticks, etc. following proper infection control procedures.
6. Utilize safe and effective practices of medication management as defined by policy including the oversight of self-administration observation of medication.
7. Administer and monitor the effects of medications, ensure accurate medication is ordered and administered for controlled substances and conduct accurate med counts.
8. Provide appropriate patient education as determined by patient assessments/needs and treatment plans.
9. Conduct introductory, 25-day and PRN meetings with patients for assigned units when in unit nurse role.
10. Monitor and/or perform withdrawal assessments and appropriately implement/instruct the necessary nursing interventions.
11. Accurately and thoroughly document in the medical record utilizing approved medical record language and abbreviations adhering to the medical record policies and procedures.
12. Schedule all patient appointments related to their medical treatment.
13. Work a flexible schedule based upon service demands and work mandatory overtime as needed.
14. Attend all mandatory trainings as identified by the facility policies.
15. Attend multi-disciplinary treatment team meetings and group sessions (when applicable) when in unit nurse role.
16. Maintain the quality control logs.
17. Provide support services for patient care issues to staff at other facilities.
18. Maintain adequate staffing for each shift.
19. Ensure the highest level of professionalism for self and staff and maintain a clean and organized work environment.
20. Complete yearly training requirements and mentor new employees.
21. This job description reflects management’s assignment of essential functions and does not prescribe or restrict the tasks that may be assigned.