Plans and provides general nursing care for patients and families in a clinical care setting utilizing a systematic approach incorporating assessment, planning, implementation, and evaluation. Collaborates with Physician and other health team members in meeting the health care needs of patients. Provides nursing services within the scope of the Nurse Practice Act, Article 139 of the New York State Education Act.
1. Diagnose and treat human response to actual or potential health problems through case finding, health teaching, health counseling and provision of care supportive to or restorative to life and well-being. (Nurse Practice Act, Article 139)
2. Collaborates with health team members in developing planning and carrying out treatment regimen.
3. Direct and supervise care delivered by medical assistants and licensed practical nurses.
4. Documents the patient's medical record with observations and action taken during patient's clinic visit.
5. Performs procedures and techniques involved in administering routine and special treatments such as vaccinations, and inhaled, injectable, and oral medications to patients in accordance with hospital Policies and Procedures.
6. Formulates, documents, and updates an individual patient education and care plan including but not limited to disease process, behavior modification, and appropriate use of medications.
7. Educates the patient and family members regarding nursing care needs.
8. Manages telephone communications including: phone triage; providing appropriate advice; directing patient to appropriate level of care; utilization review/prior authorization for patient testing and medications, communicating status to physician; addressing prescription requests; documenting actions in approved format.
9. Serves as an instructor for patient education classes and organize and manage support groups for patients and their families.
10. Reviews out-of-state program patient intakes and coordinates orders for testing.
11. Obtains patient health history for physician as needed.
12. Case management for patients with complex medical conditions.
13. May conduct annual clinical performance evaluations for unlicensed direct care staff.
14. Conducts clinical review of record to include multi-disciplinary review, coordination of care provided in conjunction with visits and documentation.
15. Performs other position-related duties as assigned.
1. Performs, as directed, safety compliance and uses Personal Protective Equipment (PPE), as needed.
2. Participates in Quality Assessment (QA) and Quality Improvement (QI) programs, as directed.
3. Ensures compliance with The Joint Commission and all other Federal, State and Regulatory Agencies.
4. Responds promptly and sincerely to customer's needs, requests and concerns via all communication forms using easily understood language and refraining from using inappropriate language and non-verbal gestures.
5. Maintains positive working relationships as a team player through problem solving issues, speaking positively about others, listening attentively and observing the Patient Bill of Rights and Confidentiality.
6. Increases customer service knowledge, skill and ability by participating in department and institution-wide specific programs.