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Registered Nurse

3 months ago


Norwalk, United States Nuvance Health Full time

**Description**

Summary:
To provide direct and indirect nursing care to a patient or group of patients.

**Responsibilities**:
1. Mental Status Exam Criteria A: Admission intake has information regarding the mental status of the patient and provides a clear picture to the reader. Mental Status Exam Criteria B: Progress notes provide information as it pertains to the patient's current mental status, including assessment of the patient's progress towards goals and updated assessment on the symptoms that were identified on admission. Mental Status Exam Criteria C: Documentation includes an assessment as it pertains to suicidal ideation and potential for harm to others. Mental Status Exam Criteria D: Discharge documentation includes an assessment as it pertains to suicidal ideation and potential for harm to others.
2. Administration of Psychiatric medications Criteria A: There is noted verbalization to patient regarding the psychiatric medications they are receiving. Administration of Psychiatric medications Criteria B: There is documentation indicating that the patient has received education regarding medication they are receiving. Administration of Psychiatric medications Criteria C: There is an assessment of the patient prior to receiving medications, so that the efficacy of the medication and side effects can be measured. Administration of Psychiatric medications Criteria D: There is an appropriate assessment and documentation for the patient who requires additional prn medications, requires the administration of medications against his/her will, and/or requires intervention with medications for symptoms of drug / alcohol withdrawal.
4. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria A: Demonstrates the ability to appropriately set limits on negative patient behaviors, the ability to assess patients for potential for violence, and intervenes appropriately. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria B: Demonstrates the ability to conduct a contraband search assuring patient rights are maintained. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria C: Exercises principles of confidentiality as it pertains to the behavioral health population. Maintainence of a therapuetic milieu and safety on a Behavioral Health unit Criteria D: Assesses the environment as it pertains to issues of safety.
5. Group leadership Criteria A: Demonstrates the ability to lead / co-lead groups exercising principles of group dynamics. Group leadership Criteria B: Leads / Co-leads the daily Community Meeting Group leadership Criteria C: Documents the patient's participation in group.
6. Patient rights Criteria A: Demonstrates knowledge of issues related to patient rights, including the requirements for the involuntary patient, and documentation reflects this. Patient rights Criteria B: Demonstrates the ability to assess the patient who request to sign out against medical advice for issues of safety. Patient rights Criteria C: Assures that the patient is aware of their rights as evidenced by the documentation that these rights have been reviewed.
7. Care delivery Criteria A: Adheres to Nursing Standards of Practice to include assessment, treatment planning, interventions and evaluation of the treatment plan, progress on the goals of the treatment plan, and the effectiveness of interventions. Goals are measurable, specific and individualized for the patient. Care delivery Criteria B: Keeps the treatment plan up to date, adding newly emerging problems and Goals to address the problems, addressing events such as a Code Green called on the patient, self-inflicted harm, a fall, etc., and signing off on Goals that have been resolved/completed, and clearly communicates these changes when handing off care. Progress Notes document the patient's progress on goals. Care delivery Criteria C: Maintains consistency in enforcing unit policies and procedures without becoming overly rigid or harsh in setting limits. Care delivery Criteria D: Demonstrates skill in therapuetic communications and interventions.
8. Patient education Criteria A: Demonstrates the ability to assess the learning needs of the patient/family and documents. Patient education Criteria B: Provides information and instruction on the nature and treatment of psychiatric illnesses and documents this information as well as the patient's response to education provided. Patient education Criteria C: Involves the patient in decisions on his or her own care, after providing education about treatments, tests, medications, appropriate behaviors, aftercare, etc.
9. Leadership ability Criteria A: As Charge Nurse, completely fills out the patient care assignment, including date, shifts, all staff on duty including floated PCTs and sitters, patients on CO and on PEC, and delegates responsibility to other members of the patient care team, commensurate with their abilities and scope of pra