RN - General

Registered Nurse – Primary CareThe Primary Care Registered Nurse (RN) provides direct and indirect nursing care in a VA clinical setting, contributing to patient assessment, determining priorities, identifying nursing measures and therapeutic objectives, and evaluating outcomes. The RN uses independent judgment, flexibility, organizational skills, and an interdisciplinary approach to provide safe, timely, patient-centered care in accordance with VA rules, regulations, policies, and standards.This is a future opportunity!Essential FunctionsArrives on time and is physically present for scheduled clinic assignments.Determines the appropriate course of treatment and communicates with referring clinicians in person or by phone as appropriate.Provides indirect nursing care by contributing to patient assessment, determining priorities, identifying nursing measures and therapeutic objectives, and evaluating outcomes.Uses independent judgment, flexibility, organizational skills, and an interdisciplinary approach in the provision of nursing care.Obtains patient history and pertinent family history.Assesses patients and plans appropriate nursing care.Documents the plan of care and care provided in the patient's medical record.Verifies transcription of physician orders and follows facility policy regarding verbal orders.Communicates pertinent patient data to the charge nurse and/or physician as appropriate.Reassesses patient condition and revises the plan of care based on identified nursing problems.Administers medications and intravenous (IV) therapies.Maintains knowledge of the actions, usual dosages, and location of commonly used emergency drugs, including those on the crash cart.Assesses and documents patient response to administered medications.Interprets cardiac rhythms and understands their clinical implications.Recognizes emergencies and initiates appropriate measures and therapies; assists with surgical and diagnostic procedures as appropriate.Instructs patients and families regarding prescribed medications, therapies, and surgical or diagnostic procedures.Assesses patient and family knowledge, implements an appropriate plan of instruction, and documents demonstrated understanding.Operates defibrillators, EKG machines, cardiac monitors, and other emergency technical equipment.Participates in discharge planning as appropriate.Assures the content and correctness of prepared reports and signs documents to validate their content.Maintains a neat personal appearance and professional decorum.Consistently applies VA customer service standards and demonstrates helpful, courteous, and respectful conduct.Respects patient rights, including visual and auditory privacy.Assesses intake and output every shift and more frequently when indicated by specific standards of nursing care.Reviews laboratory data and electronic medical records.Performs central line and ventilator care in compliance with health care system policy when applicable.Performs skin assessments and initiates measures to prevent Hospital Acquired Pressure Ulcers (HAPU).Ensures medication orders from the previous shift have been noted and either carried out or transcribed into the medical record appropriately.Carries out prescribed physician orders and documents actions in the patient's medical record.Cares for patients with a variety of catheters and prostheses.Initiates life-saving measures in the absence of a physician when necessary.Attends staff meetings as required by the facility Chief of Service, Chief of Staff, or designee and communicates conflicts that may interfere with attendance requirements.Completes appropriate Quality Management/Performance Improvement (QM/PI) documentation pertaining to procedures, complications, and examination outcomes.Completes patient documentation using the current Electronic Health Record (EHR).Documents care provided and selects appropriate Evaluation and Management (E&M) procedure codes in CPRS as required, with documentation sufficient to support the selected codes and completed by the end of each patient care encounter.Follows all established patient safety and infection control standards of care and makes every effort to prevent medication errors, falls, and patient injury.Documents patient safety events in the medical record, supports required disclosure, notifies the COR as soon as practicable but within 24 hours, and submits an entry in the Patient Safety Reporting System as required.Views the patient record within the VA Electronic Health Record and completes required VA training on proper use and operation of the computerized medical records system.Complies with computer security access agreements, confidentiality requirements, and release-of-information restrictions.Refers patient and customer service issues to the Supervisory Physician, Nurse Manager, administrative supervisor, or designee.Provides on-site patient care in a timely manner in accordance with VA rules and regulations, clinic wait-time requirements, and consult-completion standards, and reports obstacles to attendance performance measures to the COR at least monthly.Performs critical care nursing for Intensive Care Unit patients and performs scrub and circulating duties in the Emergency Department and Operating Room when assigned and within scope.Perform additional duties as assignedQualificationsGraduation from a school of professional nursing approved by the appropriate State-accrediting agency and accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE) at the time the program was completed.Current license from the Ohio Board of Nursing.Current certification in CPR by an American Heart Association vendor.Current Basic Life Support (BLS) certification; if assigned to a specialty clinic, current Advanced Cardiac Life Support (ACLS) certification is also required.A minimum of one (1) year of direct patient care experience within the last three (3) years; VA experience is desirable.Experience in Intensive Care, Medical-Surgical Units, Telemetry and Cardiac Monitoring and Emergency RoomTechnically proficient in the skills necessary to fulfill the Government's requirements, including the ability to speak, understand, read, and write English fluently.Ability to provide documentation upon request to verify current and ongoing competency, skills, certification, and/or licensure related to the provision of care, treatment, and services performed.Ability to provide verifiable evidence of all educational and training experiences, including any gaps in educational history.Ability to comply with facility Medical Staff By-Laws, rules, and regulations governing medical staff behavior.Meets Continuing Medical Education (CME)/Certified Education Unit (CEU) requirements and provides current documentation as required or requested by the facility.Possesses or obtains an appropriate National Provider Identifier (NPI), including pertinent Taxonomy Code confirmation issued through CMS/NPPES when applicable.United States citizen.Proficient in use of the VA Electronic Health Record (EHR), including review and documentation of patient information, clinical orders, progress notes, laboratory and radiology information, and other clinical records as required.Core CompetenciesDetail-oriented with strong organizational skills and the ability to prioritize patient care needs.Self-motivated with strong time-management skills and the flexibility to respond effectively to changing clinical priorities.Demonstrates sound clinical judgment, assessment skills, and problem-solving ability in routine and emergency situations.Maintains high ethical and professional standards, patient confidentiality, and respect for patient rights and privacy.Possesses strong interpersonal and communication skills and works effectively within an interdisciplinary healthcare team.Demonstrates a patient-centered customer service approach and consistently communicates in a helpful, courteous, and respectful manner.Able to work independently within scope of practice, initiate appropriate actions when necessary, and seek clinical direction appropriately.Demonstrates commitment to patient safety, infection control, accurate clinical documentation, and continuous quality improvement.Supervisory ResponsibilityThis position does not supervise or manage employees.Reports professionally to the VA Nurse Manager or designee during the workweek.On evenings, nights, holidays, and weekends, reports through the Charge Nurse to the Nursing Supervisor.TravelNo routine travel requirement is identified for this position.Patient care is provided on-site at the assigned VA facility.