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Arnot Health Registered Nurse - Outpatient - Horseheads Internal Medicine in Horseheads, New York

Job Description

MAIN FUNCTION:

Office Nurse II diagnoses and treats patient responses to actual or potential health problems through services such as case finding, health teaching, health counseling, provisions of care supportive to or restorative of live and well-being and executing medical regimes prescribed by a licensed physician, physician’s assistant or nurse practitioner. Participates in a patient-centered care team that focuses on coordinated care for individual patients, supporting patients and families to manage population health, utilizing evidence-based methodologies. A nursing regimen shall be consistent with and shall not vary from any existing medical regimen. This position reports to Outpatient Services-Director of Nursing and Clinical Services.

DUTIES AND RESPONSIBILITIES:

  1. NURSING PROCESS:

a. Assesses and cares for patients under the direction of Provider. Supervises care of licenses

b. practical nurses and medical assistants in the office setting.

c. Provides patient assessment in an ongoing and efficient manner focusing on the patient, including physical, behavioral and cognitive needs.

d. Determines patient’s care history, including test results, hospitalizations, ED case, urgent care, community care, and referrals to consultants.

e. Performs accurate triage and assessment of patient problems, prioritizes care and recognizes changes in patient status. Keeps provider informed of changes in plan of care.

f. Implements an established plan of care in a knowledgeable, skillful and consistent manner.

g. Provides age appropriate care to patients.

h. Carries out physician preapproved standing orders so that efficient and effective care is rendered.

i. Works closely with care coordinator/case manager and other members of the care team to assure patient receives appropriate education, referrals, medications and preventative care to optimize patient health.

  1. PATIENT EDUCATION:

a. Demonstrates awareness, sensitivity and knowledge of patient/family learning needs and implements appropriate measures to meet their rights and safety.

b. Utilizes educational information with explanation/directions, focusing on self-management, self-efficacy and health-promoting behavior changes.

c. Provides comprehensive education to patients on new procedures, medications etc. and documents.

d. Provides education on population management with referrals to adjunctive community services and disease management programs, as per provider order.

  1. DOCUMENTATION/OFFICE PROCEDURE:

a. Documents accurate, concise information in the patients EMR record in a timely manner:

b. Documents all interactions with patients, consultants, community agencies, or other facilities in order to facilitate the coordination and management of patient’s care.

c. Documents all orders carried out under provider or provider-approved standing orders.

i. Vital signs.

i. Problem list.

iii. Allergy list.

iv. Medication list / medication reconciliation, Prescription refills.

v. Fall assessment / pain assessment/ learning evaluation/functional limitation.

vi. Communicable Disease history.

vii. Other modules: PMH/FMH, Tobacco/Alcohol/Supplements, Substance abuse, Mental health history as well as test results, hospitalizations, ED care, urgent care, community care, and referrals to consultants since the last office visit.

  1. CARE TEAM PARTICIPATION:

a. Participates in processes that promote a functional care team, including periodic team meetings and electronic messaging.

b. Participates in the practice’s performance evaluation and quality assurance activities.

c. Assists other members of the patient-centered team to carry out their duties, practicing within the limits of his/her scope of practice.

  1. ADDITIONAL OFFICE RESPONSIBILITIES:

    a. Schedules follow-up visits, consultations, referred testing and surgeries as per provider orders.

b. Forwards appropriate information requested by consult providers.

c. Obtains pre-authorizations in a timely manner for medical testing, medications etc.

d. Is responsible for coding/billing preparation for billing dept., medical necessity and insurance referrals.

e. Processes and directs laboratory specimens in an appropriate and timely manner, submitting necessary billing information to the laboratory.

f. Performs / documents POC laboratory controls/testing as per protocol and reports results in a timely manner to the provider.

g. Assists with clerical duties such as scanning and floor stock inventory/ordering in the office when required.

h. Maintains a system to ensure receiving copies of consultation reports and test results in a timely manner with a follow up system for tracking missing information.

i. Keeps rooms stocked with appropriate medical supplies and instruments, maintaining current expiration dates and removes excess, unused supplies.

  1. SAFETY:

Demonstrates and functions with awareness of safety issues as identified by the institution towards patients, co-workers and self.

  1. EMERGENCY SITUATIONS:

Performs efficiently and appropriately in emergency situations.

a. Is aware of location of Emergency Box in their office setting.

b. Is current in CPR certification.

c. Maintains and documents daily seal integrity of office emergency box and performs monthly AED battery check.

  1. PROFESSION:

Maintains professional conduct and appearance.

a. Is courteous and respectful to patients/families and co-workers.

b. Is aware of dress code and dresses accordingly.

  1. EDUCATION:

Participates in the annual mandatory education as required by position:

a. Merit Fair, including a module on population health, in which patients’ needs are proactively addressed to optimize the overall health of the population.

b. Effective patient communication, particularly with vulnerable populations, eg. Patient coaching and motivational interviewing.

c. Aseptic Technique.

d. Mandatory inservices, including AIDET (acknowledge, introduce, duration, explain, thank), which fosters effective communication with patients.

e. Independently participates in continuing education courses to meet own professional growth.

f. Maintains a record of all educational activity.

  1. LEGAL ISSUES:

Demonstrates awareness of basic legal issues in all aspects of patient care, office functions and strives to minimize risks.

  1. OUT-PATIENT OFFICE:

Is competent to perform/assist provider with patient diagnostic testing, procedures as below, if required in the office setting, but not limited to:

a. Phlebotomy

b. EKG

c. Pulmonary Function Screening / spriometry

d. Holter monitoring/30 Day Event monitoring

e. Dermatologic procedures

f. Ear lavage

g. Pap smear

h. Staple removal

i. Specific offices only – Colposcopy, IUD insertion, Endometrial biopsy, Urodynamic study, Foley insertion/removal, Casting/Removal of cast, Allergy testing, EMG/NCS

  1. MEDICATION COMPETENCY:

Demonstrates competency in medication administration with provider order:

a. Oral medications

b. Intramuscular injections

c. Subcutaneous injections

d. Nebulizer treatments

  1. MEDICATION POLICY AND PROCEDURE:

a. Follows policy and procedure regarding medication administration.

b. Performs immunizations according to the providers instructions andaccurately documents information in the patients EMR.

c. Is responsible for maintaining clean, orderly drug sample cabinets if applicable, containing only drugs withcurrent expiration dates, by documenting on monthly samplecabinet check sheet.

d. Logs all sample medications appropriately according to policy (Sample dispensing log, SampleReceipt log) and uses sample labels appropriately.

  1. FAMILY PRACTICE NURSE ONLY:

    Nurse is familiar with:

a. State mandated (NY, PA)VFC programs/age requirements/documentation.

b. Vaccine Refrigerator Setup.

c. Monthly care of vaccine storage units and required documentation.

d. Maintains current Outpatient Services/VFC required temperature/problem logs.

  1. INFECTION CONTROL:

Performs all aspects of universal precautions when in patient careand maintains current Infection Control Certification as required by New York State (not a requirement for nurses practicing in Pennsylvania).

  1. PATIENT CENTEREDNESS:

Employee understands and demonstrates the importance of satisfying theneeds of the patient by interacting with him/her in a friendly and caring waybeing attentive to the customer’s needs, both psychologically and physicallyand maintaining communication with the patient to provide a secure and pleasant experience with the Arnot Health.

  1. OTHER:

It is understood that this list of typical job duties for the classification and is not to be considered inclusive of all job duties which may be assigned.

EDUCATION:

Graduate of an approved RN program with current New York State or Pennsylvania licensure.

EXPERIENCE:

Previous nursing experience in a medical office setting preferred. Excellent communication and writing ability.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

Basic Life Support (BLS) required within 90 days of hire date.

PHYSICAL DEMANDS:

Employee required to be on his/her feet much of the time, some lifting, reaching and stooping involved.

EXPOSURE CATEGORY:

Category I. Tasks that involve exposure to blood and body fluids/tissue.

** A.D.A Essential Functions

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