Clinical Nurse- Warren

About the role

The Clinical Nurse works as part of the care team and assists the Physicians, Advanced Nurse Practitioners and Physician Assistants in the provision of primary health care. Mainline Health Systems, Inc. involves the Clinical Nurse in continuous Quality Improvement practices and measures as set and in which the practice focus is based on a Patient Centered Medical Home model of care.

Responsibilities

• Prep electronic record each AM for patient’s appointment for the day.
• Make sure any previous labs, diagnostic imaging, or notes from referral appointments previously made, are available to provider.
• Pull paper charts for established patients if they have not been seen in clinic since EMR started. Review Share for needed documents.
• Triage patients to include:
  • Allergies
  • Vital signs—B/P, P,R,T, B/P on all patients 3 and older each visit. Peak flow should be performed on all Asthma patients.
  • LMP/Birth control for age appropriate females, Document Hysterectomy/Post-Menopausal for other females.
  • SaO2 for all patients.
  • Weight/Height/BMI on every patient. Height or length on all children. Height on adults at least yearly. Birth weight, length and head circumference on all children aged 1 and under. Head circumference on all children aged 2 and under.
  • For children aged 18 or less, current immunization record in chart, growth chart updated.
  • Check medication list each visit to ensure patient is taking prescribed medications as ordered. Over the counter medications, vitamins or supplements should also be documented. Update medication list when provider prescribes new medication, changes strength of medication or discontinues medication so that medication list is always current (EMR should do this but not always do this).
  • Remind patient that all medications (including over the counter, eye drops, vitamins, supplements, etc). should be brought to the clinic each visit.
  • Document a brief subjective statement for clinic visit.
  • EMERGENT CARE: If patient presents with shortness of breath, chest pain, severe allergic reaction, critically elevated blood pressure or temperature, critically low blood pressure, critically low or elevated pulse rate, immediately contact clinic provider or follow emergency standing orders if clinic provider not immediately available.
  • If patient presents for follow up visit for Diabetes or Cardiovascular disease, follow standing orders.
  • If patient presents with c/o pain, document site, onset and pain scale number 1-10.
  • If patient present with complaint of injury, date of injury must be documented.
  • Document anxiety screening annually, PHQ2 every month, or PRN on every patient 12 years old and older. Document PHQ9 and bipolar screenings on all patients with a positive PHQ2. Document positive screenings in chief complaints.
  • Document social history annually to include: alcohol smart form, PRAPARE form, recreational drug use, alcohol use, learning assessment, Dental home, Household environmental factors, caffeine, exercise, travel outside of the U.S, sexually active, herbal medications and OTC, advance directive.
  • The SO/GI should be documented once on each patient instead of annually tobacco smart form is performed every visit.
  • Document the pap status in chief complaints on all female patients aged 23-64. Document the mammogram status in chief complaints for all female patients aged 50-74. Document the status of colon cancer screenings in chief complaints to include iFOBT cards and colonoscopies on all patients 50-75. If ROI is obtained for mammogram, pap, and colonoscopy document in chief complaint.
  • Document the status of diabetic foot exam that is due annually in chief complaints.
  • Prepare patient for examination and set up room with needed supplies and/or equipment.
  • Absorb specimens, label specimens, and deliver them to the Laboratory.
  • Assist clinic provider in performance of diagnostic and/or therapeutic procedures.
  • Administer medications as ordered by clinic provider and document in patient EMR.
  • Make referrals for out of clinic tests and to specialists as ordered by clinic provider.
  • Do required pre-certification for insurance.
  • Send completed Medicaid Referral Form for Medicaid patients.
  • Provide patients Health Education material as needed.
  • Keep exam rooms clean and restocked. Clean exam tables, patient chairs, etc with disinfecting wipes between patients.
  • Keep all required logs current. These include: Narcotic Log—Count narcotics daily and sign that count is correct. Crash Cart Log—date and sign daily that Crash Cart is locked, Medications current (no expired medications or supplies). AED’s are checked daily for blinking green light If, applicable Lifepak defibrillator charged and discharged (unplugged on battery power every other day) place dated daily monitor strip that shows joules discharged in log, check Laryngoscope (blade light comes on) and suction. Temperature Log—Refrigerator/freezer temperature documented 2 times daily (morning and afternoon). If not within range, document that Arkansas Department of health VFC Program Directory notified and recommended action taken. Immunizations-Review patient’s (age 18 and younger) immunizations record and enter all current immunizations into the EMR. Document in notes that immunizations are current or needed. If needed, give required immunizations during current visit.
  • Receive training and follow Arkansas Department of Health VFC policies and protocols.
  • Keep nursing station neat and clean.
  • Order supplies and medications every other week.
  • Clean and disinfect surgical instruments immediately after use.
  • Fax or mail medical record requests to medical records.
  • Perform any additional assignments as designated by provider, Clinic Manager, Director of Operations, COO, CQO, or CEO.
  • Participate in monthly clinical staff meeting.
  • Serve as part of the care team; following and implementing workflows that support and sustain MHSI Patient Centered Medical Home model of care.
  • Willingness to attend and/or complete continuing education related to this position and/or any other topics as deemed necessary to MHSI.
  • Participates in daily team huddles and communicates concerns or necessary information to the care team.
  • The ability to work in a constant state of alertness and in a safe manner.

  Qualifications

  • Must have current license as Licensed Practical Nurse or Registered Nurse in the State of Arkansas.
  • Experience preferred, but not necessary.