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 to with facility policies and all applicable laws and regulations.   

Major Duties:

• Receives patient assignments and institutes nursing care for all patients.
• Provides directions, instructions and supervision to CNAs and LPN’s in the department to ensure policies and procedures are followed correctly.
• Follows 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 uses approved abbreviations.
• Administers 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).
• Receives, transcribes, and verifies provider’s orders in EHR.
• Accurately performs 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, prepares, administers, and scans prescribed medications and treatments, orally, by injection or IV, start IV’s and blood, replenishes and discontinues the same, following the six rights of administration of medications.
• Instructs and educates patients/family on medications and/or treatment throughout the hospital stay and discharge, and documents accurately in EHR.
• Establishes 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.
• Keeps 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.
• Assists providers with daily rounds and procedures, and completes requests for services in accordance with policy and procedure and document information in EHR.
• Monitors labs, CT, X-ray and physical condition and reports changes in patient’s condition to provider, and documents in EHR as needed.
• Notifies providers and documents in the EHR any significant changes in patient’s condition and reaction to drugs and treatments.
• Observes and records patient’s state of mind and response to communication.
• Consults providers and clarifies orders when necessary.
• Takes telephone and verbal orders from providers, noting the time the order is taken and the time it is transcribed.
• Inputs order in EHR for diagnostic and therapeutic services as ordered by the provider.
• Offers suggestions to improve patient care.
• Recognizes emergency situations and responds with the proper protocol as outlined in nursing policy and procedure manual. 
• Assesses/triages/observes patients for color and condition of skin, respiratory status, cardiac status, neurological, GI, renal, and GU status.
• During emergency situations, attends to patient’s and family’s needs (spiritual, educational, emotional support etc.).
• Explains procedure for care in the ER including assignment of the provider.
• Collects and records pertinent patient information during ER situations before calling the provider. 
• Completes ER records in an accurate, legible and complete manner.
• Is knowledgeable about monitor/defibrillators, chest tubes, suction, IV pumps and emergency drugs.
• Reads patients cardiac pattern, recognizing life-threatening dysrhythmias and protocol, documenting results in EHR.
• Correctly collects samples, such as urine blood, stool, and sputum from patients for testing, and performs routine lab tests samples, ensuring documentation in EHR.
• Checks stock level of supplies and pharmaceuticals and ensures equipment is in good working order. Reports anything that needs replaced or fixed.
• Assures that 24-hour chart reviews are completed on every patient.
• Keeps lines of communication open between all personnel.
• Assists coworkers by demonstration and teaching at bedside, and delegates or assigns completion of patient care by giving guidance, support, and encouragement to team members.
• Receives report and counts narcotics with nurse going off duty. Reports all discrepancies to the Acute Nurse Manager.
• Effectively carries out transfer or discharge procedures when a patient is ready to leave the hospital.
• Carries out established policies and procedures when a patient expires, and documents in EHR.
• Cooperates with scheduling polices; performs in whichever capacity patient condition, census and/or staffing levels necessitate.
• Reports 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 BLS 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 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 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.