Roles and Responsibilities:
· Provides and coordinates care by assessing physical and behavioral health needs of client, develops and implements nursing care plans, maintains medical records and educates clients and their families about various physical and behavioral health conditions while ensuring client safety at all times.
· Assesses client’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 client 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 client care. Attends and participates in the unit activities such as therapy groups, family meetings as appropriate, staffing, unit meetings, etc.
· Provides education/explanation to clients, families, and co-workers regarding medication usage/maintenance, common side effects, client’s rights, as well as other topics necessary for optimal client care.
· Monitors client acuity, census, staffing needs, and makes arrangements for coverage as needed, following established guidelines.
· Assures thorough, accurate documentation is completed for all clients on each shift and client 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.