Under general supervision, utilizes the nursing process of assessment, planning, implementation and evaluation, and theoretical/clinical skills in the promotion/maintenance of health. Incorporates evidence- based nursing practices consistent with national standards and which support quality outcomes. Assumes responsibility and accountability for the quality of nursing care rendered.
Essential Job Functions
• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Utilizing a holistic approach and evidence based nursing practices, incorporates the nursing process into the goal directed plan of care for the patient. Plan of care should include planning and scheduling of intervention/care and collaboration with other services/departments.
• Prepares and administers various medications and injections; collects and analyzes specimens as directed.
• Provides and/or assists with patient care, minor procedures and treatments within the scope of practice.
• Communicates appointments, specialty procedures, and instructions by phone, in writing, and in person; coordinates patient information with other facilities, departments, and staff as appropriate.
• Provides education, instructions, and advice to patients as directed by physician with consideration to age appropriate care.
• Responsible for documentation within clinical records (both electronic or written) of all patient care or treatments provided
• Enters physician orders into clinical information systems.
• Evaluates patient status via phone and in office setting. Advises patient appropriately (i.e., wound status, post-operative, etc.).
• Plans and organizes the work day to meet the need of the designated area.
• Provides office clerical and administrative services as directed or as needed to maximize workflow, patient through put and to maximize provider resources.
• Assists with provider documentation, charge capture and billing code capture.
• Delegates work assignments within the scope of practice to other team members (LPN, Medical Assistant or Patient Service Representative) to meet the needs of the facility.
• Plans, organizes, implements, evaluates and documents safe patient care consistent with organizational values/goals, policies and procedures.
• Adheres to patient safety standards and identifies and anticipates problems and safety issues and initiates appropriate action.
• Maintains appropriate skill/knowledge in specialty area with application and patient relevance of commonly used equipment specific to area; pharmacological application; application of laboratory values with disease process and physiological status.
• Analyzes and shares the practice implications of nursing research in specialty area.
• Performs or assists with various procedures as competency and training permit (e.g., dobutamine stress tests, conscious sedation, spirometry, IVs, and patient recovery, etc.)
• Utilizes performance improvement principles to assess, enhance, and/or improve the quality of care. Participates in the incorporation of evidence based outcomes and core principles, state survey/accreditation readiness activities, quality audits, quality improvement and patient safety teams, peer review processes, etc.
• Develops collaborative relationships with physicians and other health care providers to enhance quality practice.
• Takes responsibility for identification of own professional growth and developmental needs; meets all system/departmental educational requirements.
• Demonstrates positive, supportive, and caring behaviors in communication with patients, families, visitors, physicians, staff, and others.
• Consideration is given to the appropriateness of care based on the population specific needs of the patient. Nursing practice is delivered with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes or the nature of health problems
• Performs other duties as assigned or needed to meet the needs of the department/organization.
• Triage RN Functions
• Outreach Physician support
• Float to other nursing areas within the hospital
• Knowledge of nursing theory and practice to assess, evaluate and provide quality patient care.
• Knowledge and skill in advanced nursing assessments and procedures, aseptic technique, hazardous drugs
• Advanced knowledge and understanding of specialty services, treatments and nursing practices
• Ability to successfully complete TNCC certification within one (1) year of hire
• Analytical skills necessary to perform diverse clinical, regulatory and clerical responsibilities requiring analysis, judgment and knowledge of services/treatments
• Ability to function independently and be responsible for all requirements of conducting patient care utilizing deductive reasoning skills
• Ability to process problems independently and produce possible solution
• Work is performed independently in accordance with general directives
• Assumes responsibility for initiating necessary follow-up to maintain compliance with all clinical research trials
• Ability to resolve difficult or serious situations with input from others as needed
• Interpersonal skills which enable incumbent to assist with training and respond to other nurses’ questions and conduct community and patient education. All interpersonal relationships reflect respect, concern and courtesy for the other individual
• Ability to deal with difficult situations in a mature and professional manner
• Ability to incorporate cultural diversity and age appropriate care into all aspects of communication and patient care
• Responsible to ensure timely and accurate capture of charges for services provided
• Accountable to be fiscally responsible in selection and utilization of supplies with consideration to quality outcomes
Knowledge, Skills, and Abilities
• Common policies and procedures both organizational and departmental
• Code of Business Conduct
• Compliance Program
• HIPAA and confidentiality requirements
• Customer service techniques and Personal Service Excellence (PSE) skills
• Regulatory and accreditation standards (e.g., state survey, CMS, OSHA, etc.)
• Personal computers, hardware and software
• Nursing practices, planning and assessment within scope of practice
• American Nurses Association (ANA) Code of Ethics
• Patient safety standards
• Professional written and oral communication skills and interviewing skills
• Interpersonal skills necessary to instruct and comfort patients/residents and their families and maintain effective contacts with a variety of hospital personnel and physicians
• Analytical skills necessary to prepare evidence-based nursing care plans, coordinate and implement effective nursing care and to develop solutions to problems concerning patients/residents mental or physical well-being
• Incorporate population specific needs into all aspects of communication and patient care; scope of services provided will encompass age groups from infant through geriatric
• Utilize time management concepts or maximize time effectively
• Work effectively with nursing, allied health and medical personnel
• Concentrate and pay close attention to detail when planning and performing professional nursing care, resolving patient care problems and dealing with patients and their families
• Professionally deals with co-workers, patients, physicians, other health care providers, and visitors
• Resourcefulness in dealing with emergency situations
• May require adaptability and more diversification of duties when necessary to float to other patient care areas for varying periods of time.
• Practices within the scope of Registered Nurse licensure
• Proactively participates in survey readiness, accreditation, and other quality assurance and process improvement committees