Registered Nurse - Full Time - Days

The Registered Nurse is responsible for providing nursing care to patients.

Supervising care treatment and services of patient care provided by LPNs, CNAs and other staff on assigned unit and shift.

Developing, implementing, and evaluating an individual plan of care for each patient.

Assessment and re-assessment of patients.

Communicating appropriate information with the interdisciplinary team.

Reporting patient concerns and changes in condition to supervisor and/or physician in a timely manner.

Provides and coordinates care by assessing physical and behavioral health needs of patient, develops and implements nursing care plans, maintains medical records and educates patients and their families about various physical and behavioral health conditions while ensuring patient safety at all times.

Assesses patient’s status on an ongoing basis and pertinent information gathered is documented.

Ensures nursing treatment plans are specific to assessed needs and initial treatment plan is completed upon admission.

Takes physician’s orders (verbal or via telephone) accurately and documents appropriately; transcribes and reviews physician’s orders. Ensures physician’s orders are legible if taken verbally and transcribed appropriately per policy and procedure.

Accurately administers medications per ordered note and documents accurate count of controlled substance. Adjusts medications under provider’s supervision as needed; monitors lab results to validate medication compliance.

Notifies physician of significant changes in status such as difficulties with detox, medical emergency or change in medical status regarding response to medications, etc.

Supervises self-administration of medications using safety initiative of using two means of patient identification: documents and reports effects of scheduled and PRN medications.

Maintains accountability of administration, recording, control and security of medications, including narcotics.

Completes admission and discharge processes efficiently and accurately as directed.

Confers regularly with treatment team (e.g., nurses, therapists, program managers, physician) regarding patient care. Attends and participates in the unit activities such as therapy groups, family meetings as appropriate, staffing, unit meetings, etc.

Provides education/explanation to patients, families, and co-workers regarding medication usage/maintenance, common side effects, patient's rights, as well as other topics necessary for optimal patient care.

Monitors patient acuity, census, staffing needs, and makes arrangements for coverage as needed, following established guidelines.

Assures thorough, accurate documentation is completed for all patients on each shift and patient assignment sheets are completed daily and tasks are carried out as assigned.

Gives thorough report to oncoming staff, supervisors, and physician.

Provides coverage in emergency services as needed.