Job Specific Duties

• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care. 
• Ensures completion of patient admission history, and prepares and completes the discharge planning process accurately as per department and hospital policies and procedures. 
• Obtains parental consent for every medication administered per policy.
• Follows physician’s orders, checks labs, tests, and administers patient medications when needed. Adheres to six rights of medication administration per Medication administration policy. 
• Accesses IV sites after removal of IV to check for infiltration, redness, and infections. 
• Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate and fosters a Family Centered Care Environment. 
• Ensures safe analgesics/narcotics administration, monitoring and reassessment as per hospital Pain Management policy and procedure. 
• Completes all nursing multi-system assessment that includes head to toe, performs systems assessment based upon patient need. Performs mental health assessment. 
• Ensures appropriate restraint orders, use, documentation, and monitoring as required by Sedation policy and procedure. 
• Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation within 24 hours in the patient’s electronic health record.
• Communicates with patient and family on additional resources available to the patient. 
• Ensures voluntary consents and/ or baker acts are up to date and in good standing. 
• Coordinates all assignments and tasks for Behavior Health Techs. 
• Communicates with patients and families to review plan of care and solicits input. Communicates any patient and family concerns to physician. 
• Educates families regarding new diagnosis and provides treatment plan. 
• Promotes an “error free” working environment by consistently providing high-quality safe care as prompted. 
• Assesses all body systems, and ensures safe, efficient care, while ensuring no medication errors, avoidance of falls, and clean sweeps. 
• Provides patient information and effectively completes the hand off process at shift change and patient reassignments. 
• Demonstrates proper personal protective equipment (PPE) indication and use. 
• Actively participates in the nursing governance council and unit based activities.
• Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH, FACT, COG, COC. 
• Provides continuous supervision, observation of behavioral health patients, and adheres to non-violent crisis intervention strategies (CPI).