Registered Nurse Sample Job Description

RN’s provide and coordinate patient care, educate patients and the public about various health conditions, and provide advice and emotional support to patients and their family members.

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Summary

Provides nursing services  in compliance with regulatory guidelines. Ensures that individuals are receiving appropriate, ongoing health care and coordinates health care and documentation between families of individuals, community residences and day/work programs.

Job Results, Essential Functions & Measures of Success

Individual Medical Needs Met

Essential Functions
  1. Develops an individualized health plan for each individual with objectives and strategies that are reevaluated and adjusted as needed.
  2. Is responsible for the supervision and quality assurance of medication administration by unlicensed personnel per OPWDD and organizational Medication Administration policies. This includes review and documentation of on-site lab practicum, annual evaluation review, quarterly medication review, and reporting of medication errors.
  3. Supervises and monitors residential staff in giving healthcare to residents which complies with health care standards and regulations.
  4. Participates in the Overall Plan of Services process as medical representative and consulting nurse to the interdisciplinary team.
  5. Acts as primary contact between families, community residences, physicians' offices and day/work programs. This includes notifying families and residences when health related problems are discovered, facilitating needed services and documentation health related information.
  6. Informs staff of medical needs, restrictions, limitations and medications as they relate to individual functioning.
  7. Assesses health status of individuals in medical emergencies and ensures that appropriate treatment is received.
  8. Provides direct support to individuals and role models such support to direct support staff by assisting with living skills, communicating and interacting with individuals served, facilitating community inclusion, maintaining an appropriate physical environment, developing behavioral supports and demonstrating the importance of individuals becoming active citizens in their neighborhoods and local communities.
Measures of Success
  • Individual and family survey results indicate no concerns with nursing services
Supervisor's observation:
  • Medical concerns and questions are responded to in a way that is positively accepted by receiver.
  • Participates in service delivery process through collaboration with other team members.
  • Exceptional: Identifies, anticipates and proactively addresses medical needs.

Nursing Standards Met

Essential Functions
  1. Ensures that nursing processes and documentation are in compliance and utilized appropriately by staff.
  2. Responsible for oversight and implementation of regulatory recertification, QA and program reviews.
  3. Provides documented in-service instruction to staff on medication administration, Universal Precautions, Blood Borne Pathogens and other health-related or individual-specific topics per agency policy.
  4. Identifies individual and staff training opportunities relating to nursing/medical programs.
Measures of Success Supervisory checklist demonstrates:
  • Nursing processes and documentation are in compliance and utilized appropriately by staff
  • All OTC and prescription medications are available when needed and not outdated
Supervisors opinion that:
  • There is no pattern of POCA’s
  • There are no repeat POCA’s
  • Actions identified from audit of the nursing checklist are completed in a timely manner.
  • Achievement of goals in Nursing QI/QA plan
  • Training records are up-to-date
  • Exceptional: Reviews trends and emerging issues and implements training/systems before being asked to.

Documentation

Essential Functions
  1. Maintains accurate and timely individual assessments and documentation and strict individual confidentiality.
  2. Monitors medical recordkeeping and storage of medications.
Measures of Success
  • Periodic audits reflect accurate, complete, and up-to-date documentation
  • Zero instances of breach of individual confidentiality
Supervisor's observation:
  • # corrections required are minimal
  • Documentation contains enough detail to adequately reflect situation

Position Qualifications

Minimum Education & Experience
One year experience in a human service/medical field. Experience with individuals with intellectual and developmental disabilities preferred.

Licensure/Certification
• Licensed by the NYS Department of Education as Registered Nurse.
• Valid drivers’ license. Availability of insured personal vehicle to transport self and/or individuals as necessary.

Computer Skills
• Basic Computer Literacy as evidenced by the ability to go online and conduct basic searches on the Internet, check his/her email account, create and send e-mail with an attachment and use simple email features. Can open spreadsheets and word processing documents to read and make simple edits.

Other Skills/Knowledge/Experience
• Must have excellent communication skills including verbal and written. Must be able to summarize information and describe medical situations using descriptive, objective language.
• Strong problem-solving ability, attention to detail and the ability to adapt to quickly changing needs.
• Must be able to relate to people with sensitivity, tact and objectivity.

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