The Registered Nurse (R.N.) is a registered professional nurse who coordinates and evaluates patient care through collaborative efforts with health team members in accordance with the nursing process and the standards of care according to Texas Board of Nursing.
STANDARDS OF PERFORMANCE
THE ESSENTIAL JOB FUNCTIONS ARE CATEGORIZED UNDER THE JOINT COMMISSION STANDARDS OF PERFORMANCE.
Assess and documents medical conditions.
Document and reassess any significant changes in the patient's condition in compliance with facility policy.
Verify the accuracy of assessments and medications to include MARs and medication reconciliation.
Employ principles of communication, interviewing techniques, problem-solving and crisis intervention when performing psychotherapeutic interventions.
Intervention is based on knowledge of psychiatric and medical nursing procedures, as well as the plan of care.
Accurately administer and document medication to patients.
Transcribe and carry out physician's/licensed practitioner's treatment orders accurately.
Utilize appropriate interventions in psychiatric and medical emergencies.
Prioritize and formulate a medical/psychiatric plan of care of care based on patient assessment and according to policy.
Participate in the development of an interdisciplinary treatment plan with specific and measurable goals, objectives, and interventions defining actions unique to each patient's needs.
Update and revise the plan as goals/objectives are met or when the patient's condition changes.
Document both the nursing interventions and the patient's response to the intervention.
Assure patients are adequately oriented to the unit and program.
Monitor program activity and encourage patient participation.
Coordinate nursing care to patients, during episode of care.
Provide structure and maintain a therapeutic environment in collaboration with the patient and other healthcare providers.
Consistently utilize universal precautions and environmental safety guidelines.
Conduct structured didactic groups with patients and families as needed.
Provide education to patients and families based on their identified needs and limitations, such as medical problems, communication, interpersonal and social skills, as well as basic principles of physical health status.
Provides and documents discharge instructions including food and drug interactions, medication regimen, medication reconciliation, diets and activities as appropriate.
Evaluate and document the effectiveness of all patient teaching.
Provide opportunities for patients and families to question, discuss and explore their feelings about prescribed therapies/interventions/diagnosis and medications.
Participates in process improvement initiatives.
Collaborate with other team members, units, and departments.
Act as the patient's advocate and assures that standards of care, patient rights and HIPAA are upheld.
Comply with established measures for infection control, OSHA regulations, regulatory compliance, The Joint Commission and risk management.
Utilize time management principles to accomplish assigned duties responsibilities.
Demonstrates professionalism in communication, cooperation and provides assistance to patients, physicians/licensed practitioners, co-workers and visitors in a prompt and courteous manner. Will participate in service recovery initiatives and collaborate with grievance and complaint process.
Follow facility, departmental and personnel policies and procedures
Comply with the employee Code of Ethics/Code of Conduct.
Will be available for emergency callback tree should an internal/external disaster occurs.
Attends mandatory educational programs, minimum 75% of unit meetings, annual in-services/training and 100% of Health Stream assignments.
Demonstrates the ability to recognize high-risk behaviors and documents supporting observations in the patient's medical record.
Ability to demonstrate critical thinking, recognize medical emergencies and act within the scope of practice.
Will accept assignments and float to other units based on hospital needs.
Performs other duties and responsibilities as assigned by supervisor.
Maintains knowledge of assigned units rules, protocols and handbook guidelines.
Relates to patients developmental stages as appropriate and or age appropriate activities.
Utilize seclusion and restraint procedures with an understanding of the need for modification in regard to smaller body sizes and history trauma.
Supports seclusion and restraint hospital policy and philosophy.
Adhere to facility standards concerning conduct, dress, attendance, and punctuality.
Maintain confidentiality of facility employees and patient information
Note: The essential job functions of this position are not limited to the duties listed above.