The Registered Nurse provides leadership to the mental health treatment team during a designated shift through making patient assignments for responsibilities and activities and general supervision of programming, treatment and direct care staff. Universal Health Services, Inc. (UHS) is one of the largest and most respected hospital management companies in the nation. Heartland is a subsidiary of UHS. Standard 1 â€" Job Tasks & Knowledge-Completes position responsibilities by following established guidelines & protocols within the appropriate timeframes. Performs job functions at an acceptable level. (40%) Charge Nurse: In addition to Staff Nurse Job Criteria, performs the following: 1. Communicate specific patient information through receiving and giving shift report including, but not limited to, patients diagnosis, treatment plan issues, specific behaviors, medical issues, special precautions. 2. Make patient assignments taking into account staff capabilities and patient needs. 3. Insures the unit functions in an organized manner by: a. Assigning staff responsibility for patient education groups and topic. b. Assigning break times. c. Assigns staff to meal supervision. 4. Assesses each patient daily and documents in progress notes. Reviews flow sheet and documents behaviors noted. 5. Attends treatment team meetings to provide information re: medication compliance, response to medications, side effects, behavior, consequences, progress toward treatment plan goals and other pertinent data. Collaborates with the multi-disciplinary team in the planning and implementation of patient care. Documents synopsis of multidisciplinary treatment team recommendations. 6. Reviews treatment plan daily and makes revisions as necessary. 7. Interviews patient at the time of admission and completes Nursing Admission Assessment. Includes problems identified through mental status, physical assessment and nutritional screening and summarizes on Clinical Summary section. 8. Utilizes assessment and clinical summary to ensure all identified problem areas are addressed on the treatment plan. 9. Notes and transcribes physician orders as needed. 10. Provides leadership in identifying patient needs. Role-models or directs therapeutic interventions to de-escalate and focus on patients behavioral self control. 11. Assess and implements restraint and seclusion when all other alternative measures have been ineffective. Staff Nurse: 1. Receives report on patients. 2. Reviews physician orders, Medication Administration Records and medications. 3. Administer medication to patients in accordance with facility policy and procedures. Provides medication teaching to patients including name, dose, times, purpose and side effects. 4. Evaluates patients prescribed psychotropic medications for EPS: a. Within 24 hours of initial dose or dosage increase. b. Weekly thereafter. c. If symptoms are present. 5. Notes and transcribes physician orders. Follows through with implementing orders.. 6. Documents new admission information on designated board for History and Physicals. Utilizes time received into Heartland care as time of admission (i.e. transportation pick up time). Notifies HIS 2 hours prior to 24 hour expiration if H& P not completed. 7. Completes Admission assessments as requested. 8. Provides notification to other departments of patient needs (i.e. psych testing, nutritional consult, adjunctive therapy, etc.). 9. Completes RN assessment and documentation as requested. 10. Documents observations, treatments, interventions, patient/resident teaching and patient/resident response according to the facility and department policy and procedure. 11. Serves as a role model for patients. Residents and other nursing staff. 12. Develops a therapeutic relationship with patients/residents, using good communication skills and guided by the treatment planâ€™s goals, objectives, and interventions. Insures patientâ€™s/residentâ€™s rights. 13. Attends treatment team meetings as requested. 14. Transcribes and carries out the physicians orders, performs nursing and laboratory procedures according to facility policy and procedure. 15. Supervises non-professional nursing staff in providing quality patient/resident care. 16. Participates in Performance Improvement activities through: a. Performing unit documentation audits. b. Monitoring designated criteria. c. Performing unit safety checks. d. Participation on PI teams or do-it-groups as requested.
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