Outpatient, Family Medicine

Clinical Responsibilities

• Assists with the completion of the assessment process for patients including but not limited to the following medical checklist/physical health/nursing screening, medication list/reconciliation, depression screening, height/weight and vital signs as applicable
• Administers medications, observing the Seven Rights of medication administration
• Provides education regarding patient’s disease process
• Provides medication education for the consumer and family, including uses and potential side effects
• Monitors patients for potential side effects of medications and reports findings to the physician
• Provide direct patient care, evaluates outcomes, consults with other specialists as required and adjusts nursing care processes as indicated to ensure optimal patient care
• Accurately assign triage categories
• Maintain accurate and continued nursing documentation including patient histories, conditions, treatments, responses, pain management and assessment of changes
• Identify and address psychosocial, cultural, ethnic and religious/spiritual needs of patients and family
• Communicates effectively with the physician regarding the patient’s physical and mental condition
• Administers medical and psychiatric screenings as needed ( PHQ-2, UNCOPE, etc.)
• Completes medical checklist, AIMS, vital signs, infoscriber as indicated
• Perform ancillary testing and tasks as ordered by presiding physician (i.e. PFT, EKG, injections, audiograms, x-ray, etc.) or calls medical facility or department to schedule patient for tests
• Gives injections or treatments and performs routine laboratory tests
• Supervises nursing functions at the site including immediate supervision of medical assistants to assure conformance with established standards and procedural requirements
• Assists patients with the assistance programs and referrals; maintains updated file of referrals and provides referral information
• Responds to consumers’ request for medication refills
• Assist with meeting reporting requirements of SAMHSA grant
• Reviews chart for treatment compliance
• Follows up on missed injections and document in chart
• Interfaces with the multi-disciplinary team and actively and cooperatively participates in development of the interdisciplinary treatment plan
• Monitors laboratory results and reports all abnormal findings to the physician
• Provides emergency care as needed (CPR, MindSet, PRN medications), according to the Accordia Health Policy and Procedures
• Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation
• Participates in general and medical staff meetings as required
• Keys data into computer to maintain office and patient records
• Educate the community and patients on health issues to increase health literacy
• May conduct infection control for staff and consumers when indicated
• Performs related duties as assigned
• Meets AltaPointe Health productivity standards
• Effectively demonstrates the application of nursing competencies
• Adheres to professional code of ethics

Supervision and Consultation

• Seeks clinical supervision and consultation needs
• Accepts and employs suggestions for improvement
• Actively works to enhance clinical skills

Clinical Record Keeping

• Documents in a timely fashion per Accordia Health policy
• Documents in a clear, concise manner, types of patient problems, treatment goals and services provided
• Documentation shows that forms, notes, logs, and other applicable written information are completed promptly, accurately and updated when appropriate
• Documents legibly

Courteous and respectful attitudes towards consumers, visitors and co-workers

• Treats patients with care, dignity and compassion
• Respects patient’s privacy and confidentiality
• Is pleasant and cooperative with others
• Assists patients and visitors as needed
• Personal values don’t inhibit ability to relate and care for others
• Is sensitive to the patient’s needs, expectations and individual differences
• Is gentle and calm to patients and families

Administrative and Other related duties as Assigned

• Actively participates in Performance Improvement activities
• Actively participates in Accordia Health committees as required
• Completes assigned tasks in a timely manner
• Accesses appropriate community resources according to consumer needs
• Follows Accordia Health Policy & Procedures
• Maintains current State license and requirements for renewals (i.e. CEU’s), and attends to required in-services and workshops

Current LPN or RN license in Alabama. Must possess Basic Life Support (BLS) certification. Knowledge in adult/geriatric and/or child/adolescent specialty, outlined below, to be attained within (6) six months of employment

• Knowledge of general and psychiatric nursing care.
• Basic knowledge of psychiatric disorders in the adult and/or children populations.
• Demonstration of safe medication administration practices including IM
• Demonstrate knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patients served.
• Knowledge of medical terminology especially those terms associated with adult psychiatric care and/or substance abuse
• Maintain current knowledge of medications and their correct administration based on age of the patient and his/her clinical condition.
• Knowledge of behavior management, crisis intervention and, interventions common to acute psychotic as well as to non-violent crisis intervention practice.
• Basic knowledge of appropriate educational methods.
• Understanding of behavioral, psychological, physical health and social effects of psychoactive drugs, including alcohol and tobacco on the consumer and their significant others.
• Knowledge of trauma informed care principles
• Knowledge of cultural diversity