ACT Program- Brooklyn, NY
Myrtle Ave- Brooklyn, NY
Van Wyck Admissions
The REGISTERED NURSE is responsible for providing direct nursing care, as assigned, to agency clients in accordance with agency policies and procedures and current standards of Nursing Practice. Completes assigned duties and documents in the medical record in accordance with medical record policies and procedures.
Specific Duties and Responsibilities:
- Assesses the health status of clients assigned to the daily work schedule and developing a plan of care.
- Performs and Documents Nursing Intake/Medical History in accordance with agency policy and procedure.
- Triages sick call list as assigned and makes referrals for treatment to appropriate level of medical practitioner.
- Completes follow-up assessment of clients who are treated for chronic and/or acute illnesses to monitor effectiveness of prescribed treatments.
- Screens clients for TB by administering PPD and assessing the reaction to the PPD.
- Monitors lab values to identify abnormalities and reports such to the attending physician or physician's assistant.
- Reviews medical record to assess care being provided and to ensure continuity of care.
- Reviews entire medical record of clients to be transferred to identify problems and need for follow-up appointments or diagnostic evaluations.
- Executes orders for prescribed treatments and diagnostic testing.
- Draws blood and obtains other specimens for laboratory tests ordered by the attending physician or physician's assistant.
- Monitors vital signs and performs physical examination, as indicated to assess the health status of clients.
- Develops a plan of care for nursing care in accordance with standards of practice.
- Administers First Aid in accordance with Standing Orders approved by the Medical Director.
- Documents doses administered or packaged on the medication administration record in accordance with policies and procedures.
- Maintains flow sheets for Diabetics on insulin therapy.
- Changes dressings, wounds, and provides other treatments that are prescribed by a physician that are within the standards of Nursing Practice.
- On a rotational basis, provides "on call' 24 hour coverage, via beeper, during evenings and weekends as required.
- Documents all assessments, interventions and response to treatments in the progress notes.
- Administers and documents medications prescribed to agency clients.
- Prepares medication doses for direct administration to agency clients during clinic hours of operation.
- Maintains the integrity and completeness of the medical record in accordance with policies and procedures
- Files all feedback consult sheets in the medical record after review with the client and/or attending physician.
- Assures that all laboratory reports are noted and filed in the medical record.
- Dates and signs notes and completes them in chronological order in accordance with policy and procedures.
- Ensures the confidentiality of the medical record by obtaining appropriate consents for release of information.
- Packages doses of medication for self-administration by clients for periods when the medical clinic is closed or for clients who are permitted to self-medicate in accordance with agency policies.
- Picks up orders for treatments and diagnostic tests and completes appropriate request and/or consult forms. Notes date, time and signature for each order picked up.
- Provides patient education relative to diet, exercise, medication and treatments that are ordered.
- Coordinates and monitors the care provided by referral specialists.
- Communicates a professional image through the use of appropriate non-verbal behavior and proper attire.
- Transcribes medication orders to medication administration record and completes procedures to obtain medications from pharmacy.
- Functions as a team member to organize and prioritize responsibilities to complete work assignments, e.g. complies with changes in routine without supervision, adjusts to peaks in work load, completes priority assignments promptly.
- Takes vital signs as ordered for hypertensive clients, and documents results on flow sheet.
- Maintains inventories of stock items and orders supplies as indicated.
- Maintains narcotic records as required by regulatory agencies.
- Reviews medication orders and obtains renewal orders or orders to discontinue prescribed medications in accordance with policies and procedures.
- Uses communication skills effectively with medical Clinic staff, clients and clinical staff to maintain a positive working relationship that fosters quality medical care.
- Advises physicians and nursing supervisor of any problems that may arise in the provision of medical care that is indicated and/or ordered.
- Respects confidentiality by releasing restricted information to only those individuals who are authorized and have a need to know.
- Communicates clients' health status to treating physicians and/or physician's assistant in a timely manner.
- Maintains a calm, knowledgeable demeanor and keeps composure under stressful conditions.
- Cooperates with Medical Staff, and administration and other agency staff in a collaborative effort of providing quality medical care and a positive working relationship.
- Cooperates with physicians, supervisor and co-workers in working towards departmental goals and objectives.
- Experience in substance abuse treatment programs.
- Excellent interpersonal skills and the ability to work under pressure.
- Graduate of an accredited School of Nursing.
- Valid New York State Licensure as a Registered Professional Nurse with current registration.
- A minimum of 3 years prior clinical nursing experience with minimum of which must include 1 year of medical/surgical nursing experience in a hospital setting, preferred.
- New grads welcome to apply.