SUPERVISION OF:
Licensed Practical Nurse (LPN), Nursing Aide and Clerical staff.
POSITION SUMMARY:
Under the supervision of Hospital Administration, the Chief Nursing Officer (CNO) and the Program Director, this position as a licensed registered nurse bears responsibility and accountability for the nursing care. Inherent in the practice is the nursing process; the assessment of the patient status, the plan of nursing actions, the implementation of that plan, and the evaluation of the plan. The registered nurse assesses and monitors clients health status and physical care needed at admission and while clients are in the program. The registered nurse performs comprehensive assessments, takes off physicians orders, monitors- reconciles medications and provides health education for clients and families as needed or requested. They function as a member of the Multidisciplinary Treatment Team and perform administrative, clerical, and other tasks according to program policy. They demonstrate professionalism in all aspects of performance.
PRIMARY RESPONSIBILITIES & AUTHORITIES:
1. Performs comprehensive admission assessment to gather: presenting complaints, history, listing
all medications.
2. Prepares patients Medication Administration Record (MAR) listing all Allergies.
3. Develops a nursing plan of care, implements and documents nursing interventions that are part of
the Multi-disciplinary Treatment Plan.
4. Consults with Medical Director, Psychiatrist, Therapists and other Healthcare providers in Multi-
disciplinary Treatment Plan.
5. Attends Treatment Team meetings to discuss and update Nursing Care Plan section of Multi-
disciplinary Treatment Plan.
6. Initiates and conducts individual and group nursing education sessions.
7. Manages clients Length of Stay (LOS) to meet multiple goals.
8. Maintains a complaints log and follows up on incident reports according to hospital policy.
9. Checks for consents and notes response to medications.
10. Assists patient in understanding their diagnosis and accepting need for treatment.
11. Communicates relevant clinical and other client care information to Program Director, Medical
Director and Treatment Team members as necessary and appropriate.
12. Reports data and information requested to authorized individuals.
13. Participates in hospital committees as requested.
14. Monitors clients on an ongoing basis to identify health needs, problems, and/or symptoms.
15. Coordinates and documents clients care in cases of medical or psychiatric emergency, providing a
report to the Emergency Department or other appropriate resource.
16. Educates clients regarding bowel activity patterns to maintain regularity, prevent constipation
and impaction.
17. Maintains patient confidentiality following the organizations Policy & Procedure.
18. Monitors, observes and records patient behaviors.
19. Participates in the completion of maintenance of clients medical records.
20. Monitors environment of care to ensure a safe and secure area for patient, staff and visitors.
21. Participates in unit QAPI activities per leadership request.
22. Provides patient, family, and caregivers education on health related topics.
23. Assists clients with personal care needs (bathroom, etc.) as needed or requested.
24. Monitors and documents clients food and fluid intake at lunch to assure adequate caloric intake
and to prevent marginal dehydration.
25. Coordinates clients meals and transportation as requested or in absence of Unit Clerk.
26. Will complete other duties as assigned by Program Director or CNO.
Knowledge of:
27. Professional nursing principles, procedures and techniques used in the care of psychiatric
patients.
28. Medical and psychological terminology.
29. Medications, psychotropic drugs clinical indications and effects on patients.
30. Preparation and administration of medications.
31. State Board of Nursing Scope of Practice, Nursing Laws and Regulations.
32. Laws pertaining to psychiatric nursing and treatment.
33. Management of medical and psychiatric emergencies.
Professionalism:
34. Maintains professional appearance and behavior.
35. Completes annual educational requirements.
32. Maintains regulatory requirements.
36. Reports to work on time and as scheduled; completes work within designated time frames.
37. Wears identification while on duty.
38. Completes in-services and returns in a timely/fashion.
39. Attends all staff meetings.
40. Meets program staff development standards.
41. Observes client confidentiality.
42. Respects and protects clients legal rights.
Ability to:
43. Apply professional nursing principles, procedures and techniques used in the evaluation, care and
treatment of psychiatric patients.
44. Develop interpersonal relationship with the psychiatric patient.
45. Keep clear, concise written charts, records of patient activities, care, treatment and progress.
46. Follow:
Hospital and Unit policies and procedures.
Federal, State and Local laws and regulations.
47. Use professional judgment in determining appropriate treatment with patients in crisis.
48. Communicate calmly with patients, family and visitors in situations that require tact and
diplomacy.
49. Provide prompt efficient and responsive patient care.
50. Communicate effectively orally and in writing.
PHYSICAL DEMANDS:
The employee will be required to perform the following physical activities in the performance of their job duties:
1. Sitting/Standing/Walking/Bending Ove/Kneeling/Crouching/Stooping/Balancing
2. Pushing or Pulling/ Twisting/Reaching Above Shoulder Level/Reaching Forward & Low,
3. Fine Finger Dexterity/Lifting or carrying (up to 25-lbs regularly)
4. Ability to hear ordinary conversation is required/Vision-Close and Distance-Color and Peripheral
Employee may be exposed to patients with:
Infections and communicable diseases.
Aggressive behaviors
