Job Description

Responsible for providing professional nursing care for patients including assessment, treatment, care planning, and medical care evaluation by following established standards and practices. Assists physicians and staff in coordinating patient care. Functions as primary liaison between patients, staff, and physicians.

ESSENTIAL JOB DUTIES:

1. Obtains and documents health history, information on chief complaint, vital signs, and health risk factors and assesses disease condition.
2. Provides patient care based on practice guidelines, standards of care, and federal/state law and regulations.
3. Executes prescribed treatments and medical interventions, administers prescribed medications, and monitors and documents treatment progress and patient response.
4. Documents patient assessment and intervention data using established medical record forms/automated systems and documentation practices
5. Knowledge of professional nursing theory, regulations, and practices to give and evaluate patient care.
6. Nursing processes; health care systems, structure, and functions; and community resources. Understanding of health care technology, equipment, and supplies.
7. Familiarity with state law on nursing care, nurse practice guidelines, and clinic policies and procedures.

RESPONSIBILITIES/KNOWLEDGE/SKILLS:

1. Obtain patient consent for care and ensures patient confidentiality
2. Delegates as allowed under the Nurse Practice Act. Refers to/consults with physicians, other health providers, and community resources to prevent/resolve problems or concerns. Educates patients and families about health status, health maintenance, and management of acute and chronic conditions.
3. Participates in multidisciplinary teams to improve patient care processes and outcomes. Tracks quality assurance data and monitors for acute and chronic care management.
4. Maintains/reviews patient records, charts, and other pertinent information. Post Tests and examination results.
5. Responds to/refers incoming patient treatment-related phone calls.
6. Maintains Patient Confidentiality.
7. Nursing processes; health care systems, structure, and functions; and community resources. Understanding of health care technology, equipment, and supplies.
8. Chart/medical record documentation requirements and federal/state laws related to release of health care information.
9. Common safety hazards and precautions to establish/maintain a safe work environment
10. Time management, problem solving, multi-tasking, prioritizing, and medical care coordination.
11. Initiating appropriate crisis interventions and emergency responses
12. Patient triage in person and on the phone
13. Preparing/maintaining records, writing reports and responding to correspondence
14. Perform any other duties that may be necessary for the operation of the corporation and/or hospital

Requirements

QUALIFICATIONS:

1. High school diploma
2. RN Degree completion or nursing training from an accredited North Carolina school of nursing.
3. CPR Certificate

PHYSICAL REQUIREMENTS:

1. Varied activities including standing, walking, reaching, bending, lifting
2. Requires full range of body motion including handling and lifting patient’s manual and finger dexterity and eye hand coordination
3. Requires standing and walking for extensive periods of time
4. Occasionally lifts and carries items weighing up to 100 pounds
5. Requires corrected vision and hearing to normal ranges
6. Requires working under stressful conditions or working irregular hours
7. Exposure to communicable diseases, toxic substances, ionizing radiation, medicinal preparations, and other conditions common to a hospital and/or clinic environment