OUTPATIENT CLINIC REGISTERED NURSE

Primary function

Provides and performs oversight, delegation, and coordination of total nursing care with other health care providers to meet holistic care needs of patients. Provides care to individual patients guided by physician orders, patient’s treatment plan, policies and procedures and standards of care. Acts as a resource person for other outpatient staff members.

Duties and responsibilities

• Performs comprehensive nursing assessments in an efficient and effective manner.

• Identifies and recognizes abnormal symptoms/changes in patient condition, established priorities, and takes appropriate action.
• Administers and preforms nursing assessment in accordance with the applicable patient type which my include: Medical, Surgical, Obstetrical, Newborn, Pediatric, and or Telemetry/cardiac patient.
• Performs all aspects of blood component administration by following applicable procedures and protocols.

• Follows Lab procedure for sign out.
• Obtains patient consent appropriately.
• Ensures identification and documentation procedures are followed.
• Monitors and responds in an appropriate and effective manner to untoward events.
• Performs intravenous therapy dynamics by following administration principles in an effective manner.

• Monitors fluid replacement/electrolyte imbalance.
• Effectively handles the operations of various I.V. related equipment, including I.V. pumps and P.C.A. pump.
• Performs IV access skills proficiently.
• Administers IV additives appropriately.
• Effectively performs PICC, midline, port access and maintenance.
• Assists with other departments when no patients or procedures in unit.
• Utilizes assessment/observation and review of available data to develop a comprehensive nursing care plan that supports the medical plan for each patient.

• Utilizes NANDA approved nursing diagnosis definitions.
• Develops and individualized nursing interventions.
• Updates NCP as indicated.
• Includes patient, family, or other support system in implementation and education of interventions.
• Collaborates with Medical Staff, managements, and other health care providers to coordinated medical and nursing management of patient care.

• Promotes team concept through effective communication regarding patient condition patient care plan and patient satisfaction with appropriate individuals that are involved in the patient’s care.
• Collaborates with other departments in a professional manner as needed to provide patient-centered care.
• Directs patient support team members effectively and appropriately.
• Demonstrates initiative and flexibility in the provision of patient care.
• Informs and involves House Supervisor regarding patient care issues in a timely and appropriately manner.
• Reports significant events such as near misses, adverse events, patient/family complaints, and any situation that affects the safe delivery of patient-centered care in a timely manner.
• Is proactive and identifies opportunities for improvement.
• Ensures that handoff communication occurs any time there is a change in caregivers on the unit during shift or transfer of patient from department.
• Assists in making patient assignments, coordinating admissions, and meeting
• staffing needs for unit.
• Collaborates with all visiting providers and their staff to ensure a positive encounter.
• Carries out the discharge planning process.

• Initiates the process during admissions
• Ensures the discharge process is thorough and completed in a timely manner.
• Utilizes available Community resources.
• Completes patient and family education throughout the length of the patient’s stay and completed in a timely manner.
• Reconciles charges for services and reports information to billing department for accuracy of billing process.
• Maintains and performs all patient related documentation in a timely, factual and legible manner.

• Utilizes only approved abbreviations in all documentation.
• Accurately reflects the plan of care.
• Follows all policies and procedure related to the documentation requirements.
• Performs random chart audits to ensure staff members are following all policies and procedures related to documentation requirements.
• Maintains individual patient files with appropriate documentation for infusions, treatments, or care of a port/follow up as needed.
• Provides patient/family teaching regarding care and documents information in a timely manner.
• Performs emergency treatment as required.

• Administers and performs emergent care in accordance with the applicable patient population type which may range from newborn to geriatrics.
• Follows standards of BLS, and ACLS interventions as needed.
• Follows emergency policies, procedure, and protocols in an effective manner.
• Promotes and ensures patient safety in all aspects of responsibilities.

• Follows procedures and protocol to ensure safe administration of medications and monitoring for adverse effects.
• Ensures staff follow the hospital’s Pharmaceutical Waste Management Program.
• Ensures all infection control precautions and procedures are followed.
• Conducts or assigns LPN, to do defibrillator function testing each day of service, maintain test strip, and ensure emergency caret is locked. Will do a monthly crash cart inventory or will assign to LPN to complete.
• Utilizes proper body mechanics, transfer/lifting techniques to minimize fall risk to patient and injury to self.
• Assists with development and update of policies and procedures to maintain current standards of care.
• Implements infectious disease controls as appropriate including isolation procedures, proper use of hand washing and gloves.
• Ensures that the unit has the needed equipment and supplies to meet patient care needs.
• Performs all other duties as assigned.

Qualifications

Qualifications include:

• Graduate of accredited school of nursing.
• Currently licensed in the State of Missouri
• Minimum of (5) five years work experience on a Med-Surg Unit
• BLS, ACLS, certification required. If certifications are not current upon hire, must complete with in six months of hire.

Working conditions

Incumbent will be exposed to virus, disease, infection from patients. Usually wear a uniform and PPE. Maybe required to work long shifts. May work weekends, nights, and holidays. May also be on call.

Physical requirements

While performing the duties of this job, the employee is regularly required to speak and listen. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. This position requires intermittent physical activity, including standing, walking, bending, kneeling, stooping, and crouching as well as lifting and supporting patients.