Description Summary : Provides general nursing care to patients in a clinic or medical office. Administers medication, prepares equipment and assists physicians / healthcare providers in the treatment of patients. Responsibilities : Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process including assessment, diagnosis, planning, intervention and evaluation for assigned patients. Addresses psychological, emotional, cultural, and social needs of patient and families. Administering medications and treatments; monitoring for side-effects and effectiveness of the treatment prescribed; documenting patient history, symptoms, medication, and care given. Assess learning needs and provide education to patients, family members and / or care givers; identifying issues and resources. Utilizes the Nursing Process Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, Spiritual, and development needs of patient and families Communicates findings to appropriate healthcare team members Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice. Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s). Performs timely reassessment and documentation Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population Patient Throughput & Patient Flow Process Anticipates and plans for admission / discharge / transfer needs to facilitate patient flow Unit Operations Demonstrates good stewardship in proper use and maintenance of equipment and supplies Safe Practice / Quality Care / Regulations Incorporates patient safety practices / guidelines to promote a safe environment resulting in positive patient outcomes Demonstrates accountability for nursing research and quality improvement activities Provides evidence-based nursing care Communicates patient information effectively across the continuum of care Leadership Serves as a leader of patient care Clinical Policies and Standards Follows a specific set of standards and associated clinical procedures Analyzes policy and standards documentation and ensures organizational compliance Provides feedback for improvement of procedures Assists in the development and implementation of specific procedures Works with control and monitoring mechanisms, tools and techniques Health Information Documentation Shares experiences with maintaining paper and electronic patient documentation Walk through the steps and procedures for receiving, validating and updating patient records Describes the flow of information between various stations or units Discusses the functions, features and document flow of electronic documentation Transcribes verbal orders; explains techniques for ensuring their accuracy Medical Equipment Describes experience with basic medical equipment used in own unit or facility Uses standard diagnostic tools and techniques to resolves common equipment problems Educates patients about the appropriate use of home medical equipment Ensures that all equipment and related supplies are in proper working order prior to use Inspects, troubleshoots and evaluates incoming equipment Medical Order Processing Shares experiences with processing medical orders for one or more groups of patients or conditions Describes functions and features of the system used to enter, validate, update and forward medical orders Discusses common errors, their sources and procedures for correcting Explains considerations for entering and following standing orders Differentiates between standing orders and preprinted orders and considerations for each Patient Chart Reading and Interpretation Describes experiences in reading and interpreting patient charts for patients under own care Reviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissions Recognizes unexpected readings and alerts nursing or medical staff Relates examples of mis-readings or misinterpretations and lessons learned Reviews, discusses and validates own interpretation with others Patient Safety Shares experiences with ensuring safety for one or more patient groups or settings Explains key features of safety guidelines and procedures for those groups and settings Listens and responds to safety inquiries from patients and family members Recognizes and addresses physiological and psychological signs of problems Describes considerations for patients who can cause to harm to self, versus harm to others Requirements : Education / Skills Graduate of a Registered Nursing program, Bachelor’s Degree preferred Excellent written and verbal communication skills Experience Completion of Nurse Residency Program Six (6) months’ to one (12) months clinical patient care experience in a relevant setting Licenses, Registrations, or Certifications RN license in good standing in state of employment or a compact state , if applicable American Heart Association Basic Life Support Work Schedule : 8AM - 5PM Monday-Friday Work Type : Full Time
Registered Nurse Clinic • Balcones Heights, TX, US