Acute Care RN: Lead Patient Care & Rapid Response

Description Job Classification

Non-Exempt

Reports to Acute Nurse Manager

The Registered Nurse (RN) is responsible for working closely with the supervising provider to assess and monitor the patients’ needs, ensure treatment and care is conducted according to the procedures of the facility, administer medication and perform other related tasks in accordance with facility policies and all applicable laws and regulations.

• Receive patient assignments and institute nursing care for all patients.
• Provide directions, instructions and supervision to CNAs and LPN’s in the department to insure policies and procedures are followed correctly.
• Follow written policies and procedures as established by nursing administration in performing duties that relate to patient care and documentation regarding all aspects of patient care, and only use approved abbreviations.
• Administer professional services such as catheterization, tube feeding, suction, applying and changing dressing/bandages, perennial care, and other duties as required, assuring documentation in EHR (Electronic Health Record).
• Receive, transcribe, and verify provider’s orders in EHR.
• Accurately perform routine charting in EHR in an informative and subjective manner that reflects the care provided and the patient’s response to care.
• As dictated by the MAR, prepare, administer, and scan prescribed medications and treatments, orally, by injection or IV, start IV’s and blood, replenish and discontinue the same, following the six rights of administration of medications.
• Instruct and educate patients/family on medications and/or treatment throughout the hospital stay and discharge and document accurately in EHR.
• Establish in EHR, personalized and adequate care plans keeping them timely, coordinating care with providers and ancillary personnel, reviewing patient charts and including the family as needed.
• Keep patient care in sync with care plans by regularly reviewing them, initialing and dating any changes and ensuring other staff is aware of the details of the care plan.
• Assist providers with daily rounds, procedures and complete requests for services in accordance with policy and procedure and document information in EHR.
• Monitor labs, CT, X-ray and physical condition and report changes in patient condition to provider and document in EHR as needed.
• Notify providers and document in the EHR, any significant changes in patient’s condition and reaction to drugs and treatments.
• Observe and record patient’s state of mind and response to communication.
• Consult providers and clarify orders when necessary.
• Take telephone and verbal orders from providers, noting the time the order is taken and the time it is transcribed.
• Input order in EHR for diagnostic and therapeutic services as ordered by the provider.
• Offer suggestions to improve patient care.
• Recognize emergency situations and respond with the proper protocol as outlined in nursing policy and procedure manual.
• Assess/ triage/ observe patients for color and condition of skin, respiratory status, cardiac status, neurological, GI, renal, and GU status.
• During emergency situations attend to patient’s and family’s needs (spiritual, educational, emotional support etc).
• Explain procedure for care in the ER including assignment of the provider.
• Collect and record pertinent patient information during ER situations before calling the provider.
• Complete ER records in an accurate, legible and complete manner.
• Be knowledgeable about monitor/defibrillators, chest tubes, suction, IV pumps and emergency drugs.
• Read patients cardiac pattern, recognizing life-threatening dysrhythmias and protocol documenting results in EHR.
• Correctly collect samples, such as urine blood, stool, and sputum, from patients for testing and perform routine lab tests samples, ensuring documentation in EHR.
• Check stock level of supplies and pharmaceuticals and insure equipment is in good working order, report anything that needs replaced or fixed.
• Assure that 24-hour chart reviews are completed on every patient.
• Keep lines of communication open between all personnel.
• Assist co-workers by demonstration and teaching at…