Description
Job Classification: Non-Exempt
Reporting Relationship: Reports to Acute Nurse Manager
Primary Accountability:
The Registered Nurse (RN) is responsible for working closely with the supervising provider to assess and monitor the patients’ needs, ensure treatment and care is conducted according to the procedures of the facility, administer medication and perform other related tasks in accordance with facility policies and all applicable laws and regulations.
Major Duties:
- Receive patient assignments and institute nursing care for all patients.
- Provide directions, instructions and supervision to CNAs and LPNs in the department to ensure policies and procedures are followed correctly.
- Follow written policies and procedures as established by nursing administration in performing duties that relate to patient care and documentation regarding all aspects of patient care, and only use approved abbreviations.
- Administer professional services such as catheterization, tube feeding, suction, applying and changing dressing/bandages, perennial care, and other duties as required, assuring documentation in EHR (Electronic Health Record).
- Receive, transcribe, and verify provider’s orders in EHR.
- Accurately perform routine charting in EHR in an informative and subjective manner that reflects the care provided and the patient’s response to care.
- As dictated by the MAR, prepare, administer, and scan prescribed medications and treatments, orally, by injection or IV, start IVs and blood, replenish and discontinue the same, following the six rights of administration of medications.
- Instruct and educate patients/family on medications and/or treatment throughout the hospital stay and discharge and document accurately in EHR.
- Establish in EHR, personalized and adequate care plans keeping them timely, coordinating care with providers and ancillary personnel, reviewing patient charts and including the family as needed.
- Keep patient care in sync with care plans by regularly reviewing them, initialing and dating any changes and ensuring other staff is aware of the details of the care plan.
- Assist providers with daily rounds, procedures and complete requests for services in accordance with policy and procedure and document information in EHR.
- Monitor labs, CT, X-ray and physical condition and report changes in patient condition to provider and document in EHR as needed.
- Notify providers and document in the EHR, any significant changes in patient’s condition and reaction to drugs and treatments.
- Observe and record patient’s state of mind and response to communication.
- Consult providers and clarify orders when necessary.
- Take telephone and verbal orders from providers, noting the time the order is taken and the time it is transcribed.
- Input order in EHR for diagnostic and therapeutic services as ordered by the provider.
- Offer suggestions to improve patient care.
- Recognize emergency situations and respond with the proper protocol as outlined in nursing policy and procedure manual.
- Assess/ triage/ observe patients for color and condition of skin, respiratory status, cardiac status, neurological, GI, renal, and GU status.
- During emergency situations attend to patient’s and family’s needs (spiritual, educational, emotional support etc).
- Explain procedure for care in the ER including assignment of the provider.
- Collect and record pertinent patient information during ER situations before calling the provider.
- Complete ER records in an accurate, legible and complete manner.
- Be knowledgeable about monitor/defibrillators, chest tubes, suction, IV pumps and emergency drugs.
- Read patients cardiac pattern, recognizing life-threatening dysrhythmias and protocol documenting results in EHR.
- Correctly collect samples, such as urine blood, stool, and sputum, from patients for testing and perform routine lab tests samples, ensuring documentation in EHR.
- Check stock level of supplies and pharmaceuticals and ensure equipment is in good working order, report anything that needs replaced or fixed.
- Assure that 24-hour chart reviews are completed on every patient.
- Keep lines of communication open between all personnel.
- Assist co-workers by demonstration and teaching at bedside and delegate or assign completion of patient care by giving guidance, support, and encouragement to team members.
- Receive report and count narcotics with nurse going off duty. Report all discrepancies to the Acute Nurse Manager.
- Effectively carry out transfer or discharge procedures when a patient is ready to leave the hospital.
- Carry out established policies and procedures when a patient expires and document in EHR.
- Cooperate with scheduling policies; perform in whichever capacity patient condition, census and/or staffing levels necessitate.
- Report any patient complaints to the Corporate Compliance Officer and the Acute Nurse Manager in a timely manner, documenting any action to resolve the complaint.
Qualifications:
- Must be licensed as a Registered Nurse (RN) in the state of Kansas.
- Must be CPR certified.
- Must have or complete ACLS, PALS, TNCC and NRP certification within one (1) year of employment.
Physical Demands:
- Eye/Hand, Eye/Foot and Hand/Foot Coordination.
- Normal eyesight, with or without corrective lenses.
- Normal hearing, with or without hearing aids.
- Motor coordination and manual dexterity.
- The ability to bend, stoop, crawl, and kneel.
- The ability to exert 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly.
Work Environment:
- Well-lit/well-ventilated work area; close visual work.
- Prolonged amount of sitting, standing and walking throughout the day.
- Subject to frequent interruptions.
- May be exposed to infectious and contagious diseases.
- Meet and talk with a wide variety of employees, visitors and patients.
- Exposed to offensive odors or hazards of explosive gases.
- Exposure to unpleasant elements such as accidents, illnesses and injuries.
- Able to work under emergency situations.
- Requires judgement/action in life/death situations.
Additional Duties:
Additional duties and responsibilities may be added to this job description at any time. The job description does not state or imply that these are the only activities to be performed by the employee holding this position. Employees are required to follow any other job-related instructions and to perform any other job-related responsibilities as requested by their Supervisor or assigned charge personnel.
Employee Signature Date Supervisor Signature Date
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