Position Summary: This is a position in the Nursing department monitoring and administering medications. Deliver quality direct patient care under appropriate clinical supervision to patients with psychiatric or emotional disorders or active disease disorders or related substance or chemical dependency problems, or those dually diagnosed with psychiatric and chemical dependency disorders; to serve actively and constructively as a member of the organization’s multi-disciplinary treatment team, and support the organization’s program philosophy of care
- Administer medications as ordered by the Medical Staff utilizing established medication administration policy and procedures. Follows all protocols, medical orders, and assist the RN in providing medical care, procedures, and/or treatment for patients. Take Vital signs per medication regulations. Reports medication variations/errors.
- Attends beginning of shift change report communicating to all members of the team regarding patient care, medications, updates, training matters, and/or anything else related to patient care
- Completes end of shift narcotic count & documents any discrepancies. Preforms control drug counts as indicated by PYXIS and per policy. Retrieving control medication for pass/discharge and securing on unit. Accounting for all control medication as time of discharge and return from pass indicating count on (NS-11 form)
- Assists in setting up appointments, consultations, and ensuring the patients attend their off-ground appointments, on-site medical clinic appointments, and/or other off ground trips.
- Participates in weekly interdisciplinary treatment team meetings & provides input regarding patient response to medication and other observations
- Participates in the treatment planning process, initiating plans of care for all medications with which the patient is being treated. Checks treatment plans to update, add and sign off on interventions as needed.
- Obtains patient consent on the Medication Informed Consent Form after educating the patient about his/her medications. Adds that they were educated and gains consent on the MIC addendum when new psychotropic meds are added or substantially changed.
- Chart all medications including PRN medications on the MAR. Document indications and outcomes for PRN medications in narrative descriptions on the Multidisciplinary Progress Note, giving the behavior or reason for the PRN, and results of an assessment of the patient before and after one hour. Communicate all PRN administrations and results with the RN Charge Nurse in writing prior to the end of shift.
- Performs body audits on patients as directed by unit RN Charge Nurse including but not limited to; time of admission, off grounds visits, and prior to discharge ensuring to document the results on the body audit form.
- Writes and notes the Medical Staff orders ensuring to indicate, “read back and confirmed” (TORB) for all telephone orders. Transcribe medication orders to MAR. Scan copy of medication order to pharmacy and place copy in MAR. Transcribe all non-medication orders according to protocol completing all required forms and notifications.
- Check, clean, and document: emergency carts; controlled drugs; sharps; glucometer logs; and refrigerator temps.
- Performs Nursing Education Group and documents on a Multidisciplinary Group Note in each patient’s record, including those who did not attend.
Education: Graduate of an accredited school/college of nursing.
Experience: At least one (1) year of experience in Psychiatric or Behavioral Health and/or in the Medical field preferred.
Licensure/Certification: Currently licensed as a Licensed Practical Nurse in the State of Louisiana.