Clinic rn

General Duties, Tasks and Responsibilities

Performs accurate and complete assessment of patients presented to the Clinic; records chief complaint; assesses and reassesses pain; assessments are age, culture and psychosocial appropriate.

Adheres to scheduling template guidelines when scheduling new and return appointments; keeps schedules current; documents no show, rescheduled and/or cancelled appointments; creates telephone encounters as needed or directs calls to the appropriate staff for triage; schedules and follows-up on referral appointments and/or testing/procedures.

Assists physician(s)/providers with procedures; utilizes other departments to provide interdisciplinary care as appropriate; utilizes pain management techniques.

Follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation; obtains and documents accurate and thorough patient medical history including pertinent history, pain assessment, current medications, identified health risk factors and other needed information.

Prepares and administers medications based on age / clinical condition of the patient per policy and nursing standards of care; manages supply of medications and contacts pharmacy as needed to ensure uninterrupted medication therapy.

Educates the patient/family regarding treatment plan and follow up instructions given per provider instructions including any education handouts.

Receives patient phone calls and appropriately triages the patient condition and assists the patient as appropriate. Completes telephone encounters as needed and directs calls to appropriate staff; schedules referral appointments, testing and procedures.

Completes pre-certification for testing/procedures; ensures notification of test results for each patient is completed in a timely manner.

Communicates effectively with other specialties and disciplines to ensure continuity and quality care is maintained.

Performs all aspects of the position in an environment that optimizes patient safety and reduces the likelihood of medical/healthcare errors; utilizes established hand-off communication protocols; maintains the security of the department.

Ensures fax in-box is kept current, all documents are linked to patient accounts daily and tests results are attached to the correct patient and order; releases medical records appropriately per policy; obtains proper authorization; follows medical records documentation guidelines regarding timeliness of reviews and completeness of documentation; obtains and documents accurate and thorough patient medical history including pertinent history, pain assessment, current medications, identified health risk factors and other needed information.