Registered Nurse

Job Description

Job Description

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Conduct nursing assessments and obtain clients' medical and health histories upon admission and as clinically indicated.
• Assess clients for changes in physical and behavioral health status.
• Monitor clients for signs and symptoms associated with substance withdrawal, intoxication, medication reactions, and other medical concerns.
• Administer medications safely and accurately in accordance with physician orders, facility policies, and applicable laws and regulations.
• Maintain accurate medication administration records and controlled-substance documentation.
• Monitor clients receiving medications for effectiveness, adverse reactions, and potential complications.
• Communicate significant changes in a client's condition to the physician, Director of Nursing, Clinical Administrator, or other appropriate medical personnel.
• Respond appropriately to medical emergencies and initiate emergency procedures when necessary.
• Coordinate emergency medical services and transfers to hospitals or other healthcare providers when clinically indicated.
• Obtain and document vital signs, including blood pressure, pulse, temperature, respirations, oxygen saturation, and other clinical measurements as required.
• Provide wound care, basic nursing treatments, and other nursing interventions within the RN's scope of practice.
• Assist with admission, discharge, and transfer procedures.
• Review medical orders and ensure that nursing interventions are carried out appropriately.
• Provide health education regarding medications, substance use, overdose prevention, infectious diseases, nutrition, hygiene, and other health-related matters.
• Support clients receiving medication-assisted treatment/MOUD as applicable to the program.
• Identify and report suspected medication errors, adverse drug reactions, injuries, abuse, neglect, or other reportable incidents in accordance with agency policy and applicable requirements.
• Maintain confidentiality of client information in accordance with HIPAA and agency policies.
• Complete timely and accurate nursing notes, assessments, medication records, incident reports, treatment-plan documentation, and other required clinical records.
• Participate in treatment team meetings and communicate relevant nursing information to the interdisciplinary treatment team.
• Collaborate with counselors and other clinical staff regarding clients' medical needs and treatment progress.
• Assist in maintaining a safe, clean, and therapeutic environment for clients.
• Monitor and maintain appropriate nursing supplies, medications, and medical equipment.
• Follow infection-control, emergency preparedness, workplace safety, and medication-management procedures.
• Participate in quality improvement activities, audits, staff meetings, and required in-service training.
• Maintain current CPR/BLS certification and any other certifications required by the facility.
• Maintain professional boundaries with clients and comply with the agency's code of conduct.
• Perform other nursing duties as assigned by the Director of Nursing or Clinical Administrator.