Responsibilities Overview

Assessment

  • Assesses patient’s physical, social and behavioral, mental status through direct observation, interview, and medical record review.  
  • Utilizes observational skills to assess patient’s needs.  
  • Documents a nursing assessment to include psychosocial, environmental factors, educational level and needs.  
  • Obtains and reviews available data base and any data collected by other members of the health team (medical, surgical or other history, physical exam mental status, therapist reports and community referrals).  
  • Identifies medical problems resulting from mental illness and use of medications.
  • Communicates findings with other members of the health team. (Social Worker, Case managers, therapist, physician).  

Planning

  • Identifies and addresses needs for admission based on acute medical and surgical diagnoses and presenting physical or psychological symptoms. 
  • Identifies and addresses patient level of education, learning needs.
  • Makes appropriate referral to other disciplines and documents same. 
  • Intervention and Implementation 
  • Management of clinical skills in the provision of nursing care and management of the patient including but not limited to: 
  • Identification of symptoms  
  • Management of the disease entity  
  • Treatment modalities  
  • Administration of medications  
  • Intervenes appropriately in medical and surgical emergencies utilizing non-violent crisis intervention.  
  • Utilizes infection control procedures; collaborates with the infection control department in preventing and controlling infection control.  
  • Practices infection control: personal hygiene; hand washing; and dress code  
  • Provides for psychosocial and educational needs of all medical and surgical patients.  
  • Provides health teaching and medication instructions. 
  • Ensures that all procedures are performed based on established standards of care  
  • Demonstrates competency in performing all procedures within the scope of practice and in accordance with facility
  • Investigates and communicates all required information regarding unusual occurrences or patient care incidents.  
  • Acts as a patient advocate.  

Qualifications Education

Bachelor’s degree in Nursing.  

Experience

Minimum three (3) years' medical-surgical nursing experience preferred. 

Licenses and Certifications

  • Current NY State RN License required.  
  • Basic Cardiac Life Support (BCLS) required.  
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