Job Supervisory Responsibilities: May participate in supervision of medical assistants, medical administrative assistants, licensed practical nurses, and certified nursing assistants

General Summary: An exempt position responsible for providing primary care to patients, including assessment, treatment, care planning, and medical care evaluation.

Essential Job Responsibilities:

1. Obtains patient consent for care and ensures patient confidentiality. Obtains and documents health history, information on chief complaint, vital signs, and health risk factors and assesses disease condition. Provides patient care based on practice guidelines, standards of care, and federal/state laws and regulations.
2. Executes prescribed treatments and medical interventions, administers prescribed medications, and monitors and documents treatment progress and patient response. 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. Documents patient assessment and intervention data using established medical record forms/automated systems and documentation practices.
4. Participates in multidisciplinary teams to improve patient care processes and outcomes. Tracks quality assurance data and monitors for acute and chronic care management.

Education: RN. Completion of nursing training from an accredited school of nursing. BSN preferred.

Experience: Minimum one year of professional nursing experience. Clinic experience preferred.

Other Requirements: Current state registered nurse license. Current CPR certificate.

Performance Requirements:

Knowledge:

1. Knowledge of nursing processes; health care systems, structure, and functions; and community resources. Understanding of health care technology, equipment, and supplies. Familiarity with state law on nursing care, nurse practice guidelines, and clinic policies and procedures.
2. Knowledge of wellness/illness, growth and development, human behavior, psychosocial factors, and alternative health care treatments.
3. Knowledge of chart/medical record documentation requirements and federal/state laws related to release of health care information.

Skills:

1. Skill in time management, problem solving, multitasking, prioritizing, and medical care coordination.
2. Skill in initiating appropriate crisis interventions and emergency response.
3. Skill in patient triage in person and on the phone.

Abilities:

1. Ability to analyze options and then counsel patients and families about choices and make referrals to other providers and resources.
2. Ability to engage clients and families in the development and implementation of a care plan.
3. Ability to read and interpret physicians’ orders and notes from other providers.
4. Ability to calculate and administer drug dosages and injections and measure results.

Equipment Operated: Standard nursing equipment and supplies including thermometer and syringes. May involve use of assistive devices such as walkers, wheelchairs, ventilators, pulse oximetry units, and oxygen tanks. May require use of computer.

Work Environment: Medical exam/treatment rooms and medical offices. Controlled lighting, acoustics, air quality, and temperature settings. Environmental hazards may be unpredictable including exposure to communicable diseases and biohazards.

Mental/Physical Requirements: Involves standing, walking, bending, grasping, manipulating, and squatting. Occasional need to lift patient during transfer/turn process with or without assistance. Stress can be triggered by workload and complex cases.