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RN CLINICAL DOCUMENTATION SPEC
University of New Mexico - Hospitals
ALBUQUERQUE, NM 87101
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University of New Mexico - Hospitals

ALBUQUERQUE, NM 87101
Posted at 29 Jan, 2024

Description

UNM Hospitals participates in the Clinical Advancement Program (CAP) and depending on your Nursing Education and National Certifications, you’ll work towards one of five CAP levels that offer increasing compensation. You may earn up to $8.00 in addition to base pay.

Sign-on Bonus and Relocation Reimbursement available!

Receive 17% weekday nights and 26% weekend nights shift differentials!

Department: CPC Acute Services
FTE: 0.90
Full Time
Shift: Nights

Position Summary:
Provide professional nursing care for assigned patients in a mental health/psychiatric environment. Design nursing care plans and assist in the development of overall care plans for psychiatric patients, ensure administration of appropriate overall care in a manner conducive to recovery. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include pediatric, adolescent, adult and geriatric age groups.

Detailed responsibilities:
* PATIENT CARE - Interview, examine, and assess the health status of psychiatric patients with various cognitive, emotional, developmental, social, and behavioral disorders
* PATIENT CARE - Observe patient behavior, activities, and mental status; perform triage and crisis intervention
* PATIENT CARE - Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions
* PATIENT CARE - Chart and report observed symptoms, reactions, treatments, and changes in the patients' conditions; collect and document data and information; may perform computerized data entry
* PATIENT CARE - Perform nursing intakes, draw blood and other patient specimens; may perform or coordinate laboratory tests
* PATIENT CARE - Educate patients and families on treatment regimens, management of side effects, and compliance with the treatment plans; provide emotional support and acts as advocate for patients and families
* PATIENT CARE - Provide information and facilitate communication between physicians, medical students, staff, patients, families, and community; coordinate and consult with a milieu of service providers
* POLICY & PROCEDURE - Follow established departmental policies, procedures, and objectives, continuous quality improvement objectives, and safety, environmental, and/or infection control standards
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
* ADMINISTRATION - Perform various administrative functions such as monitoring expenditures and preparing reports and correspondence; may participate in a variety of research projects to develop service plans; may propose changes to program policies and procedures
* PRECEPTOR - Participate in orientation, and having successfully completed preceptor training, assume precepting and evaluation responsibilities of new personnel
* TESTS AND PROCEDURES - Assist with special tests and procedures, ensure proper consent has been obtained
* EMERGENCY MEASURES - Assist with or institute emergency measures for sudden, adverse developments in patients
* MEDICATION - Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings
* ENVIRONMENT - Maintain a safe, comfortable, and therapeutic environment for patients/families in accordance with Hospitals standards
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"

Qualifications


Education:
Essential:
* Program Graduate
Nonessential:
* Bachelor's Degree
Education specialization:
Essential:
* Nationally Accredited Nursing Graduate
Nonessential:
* Nursing

Experience:
Essential:


Nonessential:
Bilingual English, Spanish, Keres, Tewa, Tiwa, Towa, Zuni, or Navajo 1 year directly related experience

Credentials:
Essential:
* CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days
* RN in NM or as allowed by reciprocal agreement by NM

Physical Conditions:
Heavy Work: Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly to move objects or people. Physical Demand requirements are in excess of those for Medium Work.

Working conditions:
Essential:
* Sig Haz: Physical risk/injuries due to combative patients
* Sig Hazard: Chemicals, Bio Hazardous Materials req PPE

Department: Registered Nurse