Nurse- Sheridan

Clinical Nurse

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.

Essential Functions:

• Prep electronic record each AM for patients 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 signsB/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.
• If patient is a diabetic, document the status of the diabetic foot exam that is due annually in chief complaints.
• 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. Pap ROI must be documented in pap log.
• Prepare patient for examination and set up room with needed supplies and/or equipment. Assist provider with patient examination as needed.
• Collect specimens, label specimens, and deliver them to the Laboratory. SBHC nurses are responsible for collecting and transmitting labs. Patients first initial, last name, date of birth and account number should be on all specimens taken to lab.
• Assure written consents are obtained and witnessed for clinic surgical procedures.
• 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. All referrals should have documentation for when an appointment is made, requested information is faxed, and when patient was notified of appointment date and time and any instructions given to patient. Referrals should be kept in Active status until documentation from referral appointment received and scanned into note and documented. Then status should be changed to Addressed.
• 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 LogCount narcotics daily and sign that count is correct.
• Crash Cart Logdate and sign daily that Crash Cart is locked, Medications current (no expired medications or supplies). AEDs 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 LogRefrigerator/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 patients (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.
• Multi-dose medication vials are good until expiration date. All medications and supplies are to be checked for daily for expired dates.
• Wear proper PPE as necessary for job. Gloves, Mask, Gown, Eye Protection, Shoe Covers all available and stocked in Treatment Room.
• Use Biohazard bags and Sharps containers. Disposal of biohazard materials is responsibility of nursing staff, not housekeeping staff.
• Clean and disinfect surgical instruments immediately after use. Allow instruments to stay in Cetylcide solution for 30 minutes only, remove and rinse with water, place in instrument lubricant for 30-45 seconds, remove and place open on paper towel or under pad and allow to air dry. Wrap, date (date autoclaved and expiration date) and autoclave. Restock to designated area after autoclaved. Double wrapping in Sealing Sterilization Pouches allows 1-year expiration date. Single wrapping allows for 30-day expiration.
• Autoclave spores on 20th day of each month and mail the spores to Mesa labs for reading to verify autoclave is functioning properly.
• Fax or mail medical record requests to medical records.
• HIPAA/Patient PrivacyCareful to keep medical information Confidential. Do not talk in hallways. Use low voice. Give medical information only to person authorized to receive it. Do not discuss medical or personal information through receptionist window. When EMR not in use or you step away from it, close it or turn it off to prevent accidental HIPPA violation.
• Notify OSHA officer immediately of any needlestick or sharps injury of Blood Borne Pathogen or Other Potentially Infectious Materials Exposure within clinic to self or any MHS employee. Fill out proper paperwork as directed by OSHA officer.
• Fill out Incident Report for any accident that occurs to any employee, Patient, or visitor on Mainline Health System Inc. property. Notify clinic provider of accident to assess and treat as necessary.
• Maintain medical records including consultation reports, x-ray reports hospital admission and discharge forms, etc. Scan all reports in a timely manner so that EMR is current for each patient.
• Assist patients with indigent drug programs including Delta Medicine Assistance Program and 340B.
• Perform any additional assignments as designated by provider, Clinic Manager, Director of Operations, COO, CQO, or CEO.

Participates