Medical records nurse, lpn | Fairhope, AL

Detailed Information

  • Location: Fairhope, AL

and depends upon the consumer's presenting symptoms. Clinical Responsibilities + Completes Nursing backssment as indicated by Alta Pointe's Policy and Procedure + Responds to consumers' requests for medication refills. Reviews charts for treatment compliance.

+ Administers medication observing the seven rights of medication administration and ordering of medications to the shop + Performs venipuncture for laboratory requests, drug screens, TB skin tests, monitors lab results and reports all abnormal findings to the physician + Provides individual, family and group education regarding consumer's psychiatric illness + Provides medication education for the consumer and family, including

uses and potential side effects. Monitors consumers for potential side effects of medications and reports findings to the physician/CRNP/RN + Communicates effectively with the physician regarding the consumer's physical and mental condition + Follows up on missed injections and documents in consumers record appropriately + Completes admission procedures for consumers and updates accordingly to Alta Pointe's Policy and Procedures.

This process includes at a minimum: medical checklist, AIMS, vital signs, Medication List, and MARS if applicable + Documents on, Updates, and reconciles MARS if applicable + Interacts with consumer and evaluates needs to ensure that proper information is reported

during staffing with the treatment team + May conduct infection control training for staff and consumers when indicated + May provide HIV education + When necessary provides nursing coverage to other Adult Outpatient programs within Alta Pointe + Interfaces with the multi-disciplinary team and actively and cooperatively participates in development of the interdisciplinary treatment plan.

For Psychopharm consumers, the nurse will create and update the treatment plan as needed. + Provides emergency care as needed (CPR, Mindset, Emergency Medications), according to Alta Pointe Policy & Procedures + Demonstrates the ability to recognize the elements of a crisis state and knows how to deescalate or resolve the situation + Adheres to professional code of ethics + Effectively demonstrates the application of adult specific competencies Supervision and Consultation + Seeks clinical supervision and consultation needs + Accepts and employs suggestions for improvement + Actively works to enhance clinical skills Clinical Record Keeping + Documents in a timely fashion per Alta Pointe policy + Documents in a clear, concise manner, types of consumer problems, addresses treatment plan goals and objectives and progress regarding those goals/objectives and services provided in the direct service record + Documentation shows that forms, notes, logs, and other applicable written information are completed promptly, accurately and updated when appropriate + Documents legibly + Meets Alta Pointe productivity standard Courteous and respectful towards consumers, visitors and co-workers + Treats consumers with care, dignity and compassion + Respects consumer's privacy and confidentiality + Is pleasant and cooperative with others + Assists consumers and visitors as needed + Personal values don't inhibit ability to relate and care for others + Is sensitive to the consumer's needs, expectations and individual differences + Is gentle and calm to consumers and families + Works in a dependable, cooperative and positive manner with both program and other Alta Pointe staff members Administrative and Other related duties as assigned + Actively participates in Performance Improvement activities + Actively participates in Alta Pointe committees as required + Completes assigned tasks in a timely manner + Accesses appropriate community resources according to consumer needs + Complies with Alta Pointe policies & procedures + Maintains current State license and requirements for renewals (i.

e. CEU's), and attends to required in-services and workshops LPN or RN license in the state of Alabama ID: 2023-20646 # of Openings: 1 Shift/Hours (ex: Monday-Friday 8:00-4:30): m-F 8:00-4:30 External Company Name: Alta Pointe Health External Company URL: For more details: jobs-search. org/real-estate_fairhope-c424326/medical-records-nurse-lpn-fairhope_i1959167477

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