Obtains patient consent for care and ensures patient confidentiality. Obtains and documents health history, information on chief complaint, vital signs, and health risk factors and assesses disease condition. Provides patient care based on practice guidelines, standards of care, and federal/state laws and regulations.
Executes prescribed treatments and medical interventions, administers prescribed medications, and monitors and documents treatment progress and patient response. Delegates as allowed under the Nurse Practice Act. Refers to/consults with physicians, other health providers, and community resources to prevent/resolve problems or concerns. Educates patients and families about health status, health maintenance, and management of acute and chronic conditions.
Documents patient assessment and intervention data using electronic medical record and documentation practices.
Participates in multidisciplinary teams to improve patient care processes and outcomes. Tracks quality assurance data and monitors for acute and chronic care management.
Maintains/reviews patient records, charts and other pertinent information. Posts tests and examination results.