Description
Duties & Responsibilities:
- Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Perform/document nursing assessments and screenings including reviewing client histories and documenting a nursing clinical summary on all clients admitted to Origins.
- Assess individual client care needs, initiate medical treatment plan and competently process/implement all care according to physician orders and standards of nursing practice.
- Utilize safe and effective practices of medication ordering and management as defined by policy and standards of nursing practice.
- Accurately administer and monitor the effects of medications and conduct accurate controlled medication counts.
- Processes physician orders in a timely and accurate manner
- Collect and process lab specimens following proper infection control procedures.
- Provide appropriate client education as determined by client assessments/needs and treatment plans.
- Delegates some duties and coordinates care with other direct-care staff to ensure continuity of client care, staff relations, and efficiency of service.
- Prepares and maintains client medical records including appropriate and timely documentation.
- Accurately and thoroughly documents in the medical record utilizing approved medical record language and abbreviations adhering to the medical record policies and procedures.
- Provide thorough and accurate shift report to ensure continuity of client care.
- Work a flexible schedule based upon service demands.
- Attend all mandatory trainings as identified by Origins policy.
- Complete yearly training requirements and mentor new employees.
- Effectively communicate medical/ nursing issues to clinical/case management team and serves as a resource.
- Uphold all Origins Behavioral HealthCare Policies and Procedures.
- Maintain client/potential client confidentiality in accordance with Origins’ Policy.
Additional Responsibilities
- Be responsible for the health, safety, and welfare of clients.
- Ensures the privacy and confidentiality of all clients and their medical records.
- Completes duties in a professional and timely manner.
- Reports all alleged incidents of abuse or neglect in accordance with all state standards and accrediting bodies.
- Ensures that all records are available for all state and accrediting bodies staff inspection.
- Ensures and coordinates with the clinical staff’s functioning, so as to avoid scheduling conflicts for clients, between Administration, Clinical, and programmatic needs or requirements set-forth by the Standards.
- Stands "On Call" at designated times, and;
- Reports directly to the MD/PA/ANP and completes orders in a professional and timely manner.
Requirements
Education/Experience/Qualifications:
- Associate (ADN) or Bachelors (BSN) degree.
- Currently licensed as an RN is required.
- Current CPR/First Aid training/certification.
- Previous hospital, chemical dependency rehabilitation treatment program, and/or behavioral health experience desired.
- If in recovery, two (2) years of continuous sobriety preferred.
Knowledge/Skills/Abilities
- Possess a working knowledge of addictions with age specific client populations preferred.
- Working knowledge of personal computers and basic software.
- Must be computer literate and be familiar with most Microsoft products and network components.
- Must have fluid communication skills.
- Must possess a high degree of organization skills.
Competence/Measurements
- Family, referral and client satisfaction – documentation/interviews.
- Compliance with all state standards and accrediting bodies – documentation.
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
