NURSE PRACTITIONER I-Primary care

Evaluates, examines, diagnoses, and treats patients

Maintains and promotes the well-being of the patient through preventative healthcare and guidance.

• Provides care in the outpatient setting only - predominately Monday through Friday
• Ensures that the assessment of the patient and the direct and indirect patient care delivered is in accordance with appropriate licensing board, hospital policies, procedures, and protocols, and all other professional standards of care.
• Collects patient assessment data in a systematic manner, focusing on the physical, psychosocial, age, cultural, and spiritual needs of the patient.
• Performs systematic physical exam and history of present illness.
• Documents assessment data, history of present illness, and physical findings on the appropriate medical record within established time frame.
• Involves the patient/family and other healthcare providers when appropriate.
• Manages the physical and psychological problems of the patient. Identifies normal and abnormal findings. Implements an individualized plan of treatment, reassess and revises plan as needed.
• Evaluates the physical and emotional responses to medications and treatments. Prescribes immunizations per recommended schedules. Seeks appropriate consultation.
• Develops an educational process for the provision and coordination of patient care activities that promote and maintain health, fosters self-care and improves outcomes.
• Participates in the assessment of the patient’s readiness to learn, identifies the educational barriers and tailor the educational process to meet the needs of the patient/family.
• Acquires and distributes educational resources tailored to the patient's needs. Provides appropriate instruction and guidance regarding immunizations.
• Communicates effectively with the physician and other healthcare providers to achieve desired outcomes and assure a continuous flow of patient care.
• Initiates and maintains the Problem/Medication list at each encounter. Complies with completeness, accuracy, and timeliness of documentation at each encounter.
• Assesses the patient and facilitates consultation when indicated. Directs patient to appropriate level of care and communicates all pertinent information.
• Assists in identifying and utilizing resources and/or social agencies for further treatment or rehabilitation.
• Participates in Performance Improvement activities designed to enhance the quality of patient care, customer service, or practice efficiencies.
• Identifies initiatives to improve patient outcomes, satisfaction, or efficiencies.
• Assists in chart reviews/audits as needed for performance improvement data collection.
• Supports initiatives implemented to improve patient outcomes and/or office efficiencies.
• Demonstrates Leadership by utilizing the concepts inherent to the practice of the professional nurse.
• Demonstrates an ability to solve problems independently utilizing critical thinking skills and seeks assistance from immediate supervisor when appropriate.
• Maintains accountability for actions taken.
• Effectively functions as a resource person.
• Acts as a patient advocate.
• Performs effectively in the role of preceptor/mentor to new hires and/or students.
• Assists in maintaining/decreasing organizational/departmental costs.
• Completes all competency requirements annually.
• Provides for patient safety in compliance with hospital and physician practices policies.
• Adheres to infection control processes, including standard precautions, to reduce the risk of acquiring or transmitting infections.
• Utilizes two forms of patient identification before implementing any form of patient care.
• Practices all National Patient Safety Goals.
• Assists in the department's compliance with all regulatory agencies.
• Participates in continuous survey readiness for inspections and surveys.
• Participates in the non-punitive medication reporting system.
• Ensures accountability for narcotics per regulatory/organizational policies.
• Participates in office fire, safety, utility, hazard, and disaster drills as required.

Performing Procedures, Assisting in Surgery, and Providing Care

Positions patients and assists surgeon in the operating room. Prepares and drapes the patient as per established guidelines. Assists in surgery by performing tasks defined by the surgeon. Assists and maintains sterile techniques through procedures. Prepares for and develops discharge planning in conjunction with supervising physician. Dictates discharge summaries timely and appropriate. Provides counseling and instruction to patients and or families as appropriate. Performs clinical responsibilities in a manner that maximizes patient care and outcomes. Assumes appropriate code team role during emergency situations and responds effectively. Facilitates timely treatment of abnormal labs or other relevant findings. Develops workflow patterns to facilitate patient transfers or discharges. Participates in outcome management and Press Ganey scores.

Interviews, Evaluates, and Assesses Patients

• Interviews, evaluates and assesses patients in the clinic setting. Provides recommendations for treatment.
• Evaluates patient's current status providing recommendations for ongoing treatment.
• Assesses for alternate levels of care as necessary.
• Adjusts medication as indicated.
• Provides patient/family education regarding medication, rationale for use and possible side effects.
• Collaborates with the supervising physician and or substitute supervising physician and members of the treatment team to achieve desired outcomes and to assure continuous flow of patient care.
• Alerts the treatment team to any significant changes in the patient's status.
• Within prescribed time frames reviews treatment goals and objectives with patients making modifications as appropriate.
• Communicates pertinent information timely and efficiently to the supervising or substitute supervising physician.
• Documents in the medical record. Records patient's current mental status. Documents all screenings and assessments performed. Records medication changes, prescriptions written and samples provided. Documents patient's complaints, concerns and questions as appropriate. Documents any/all telephone contact with patients, families, pharmacists or physicians.