Position Summary
The Registered Nurse (RN) interacts with the clients and team members throughout their shift, assisting direct care staff in meeting client’s functional needs. The RN collaborates with team members to ensure a safe and therapeutic environment is maintained within the treatment facilities. Position performs various tasks related to the provision of medical care to include taking physician orders, preparing, and administering medications, assessing and document client’s health and mental status, and coordinating health/medical services in accordance with physician orders.
Relationships and Contacts
Within the organization: Maintains frequent and close working relationships with facility leadership, Director of Nursing, Medical Director, Medical team including Nurse Practitioners and Physicians Assistants, Clinical Director, direct care team members, and quality/compliance team members.
Outside the organization: May initiate and maintain working relationships with clients, third party providers, pharmacies/suppliers, labs, and vendors, as needed.
Essential Responsibilities
- Provides a comprehensive nursing assessments identifying client’s medical needs, capabilities, and limitations.
- Records and transcribes physicians written and verbal orders, conducting or delegating STAT orders immediately, as needed.
- Communicates observations and recommendations for clients’ plan of care, providing input into the treatment team process, as needed.
- Identifies abnormal diagnostic data and brings to the attending physician’s attention.
- Documents the administration of medication in according to established policies and procedures.
- Coordinates pharmacy and laboratory orders, delivery, and refills with the appropriate vendors, as needed.
- Maintains responsibility for the security of all controlled medications kept in the facility and monitors the administration and accurate recording of use.
- Administers medications/injections according to physician orders and medication administration record.
- Collects blood, urine and other laboratory samples as ordered by the medical providers.
- Provides, structures, and maintains a therapeutic environment in collaboration with other staff.
- Documents observations in nursing assessment and daily notes in electronic charting system, in accordance with facility policy in a timely manner, reflecting plan of care outlined in the medical record and treatment plan.
- Documents ongoing assessments of client behaviors and presentation, reporting concerns to team members in a timely manner.
- Completes incident reports in accordance with established policy and procedure.
- Prepares clients for discharge, provides individualized medication instructions prior to discharge in a clear and concise manner; providing written instructions if needed.
- Provides education to clients and families about medications, side effects, contraindications, and physical symptoms.
- Assists in the coordination of admissions, transfers, and discharges to provide a smooth and efficient flow of communication.
Additional Responsibilities
- Functions within the guidelines of the facility’s Code of Ethics and in accordance with corporate compliance.
- Conducts chart audits following program policy timelines, as requested.
- Consistently arrives to work on time, rarely missing shifts, and promptly notifies supervisor when absent.
- Demonstrates an ability to adapt to changes in the facility function, management styles, and facility routines.
- Adheres to facility policies, procedures, rules, and regulations, implementing regularly.
- Collaborates with team members to ensure a client needs are consistently met with a high level of customer services.
- Attends and completes all training within assigned time frames as required by the facility.
- Performs other duties as assigned.