Nurse- Women's Health Monticello

Clinical Nurse

Department:
Nursing | Job Status:
Full Time | FLSA Status:
Non-Exempt Position |

Reports to:

Clinic Manager | OSHA:
High Risk Position | ADA:
Negotiable Position

Work Schedule:

• 8 a.m. to 5:30 p.m., Monday-Thursday, Friday 8 a.m.
  
  -12:00 p.m.
• 8 a.m. to 4:30 p.m., Monday-Thursday (Eudora & Wilmot), Friday 8 a.m-12:00 p.m.
• 7 a.m. to 4:30 p.m., Monday-Thursday (Portland Only), Friday 8 a.m-12:00 p.m.
• 7 a.m. to 3:30 p.m., Monday-Friday, School Clinics (except Dermott 7:00 a.m.
  
  -11:00 p.m.)

However, adjustments in schedule or additional hours may be required to complete duties. Extended hours for Friday afternoon and Saturday morning clinics are required on a volunteer basis.

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.

• Prep electronic record each AM for patient’s 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 signs—B/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 PHQ
    2. 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…