Bachelor's degree, Associate degree, or Diploma from accredited School of Nursing
Current Montana RN license
Current CPR certification
Outpatient clinic experience
Knowledge of electronic health record operating systems
To assist clinic providers and staff in the deliverance and coordination of patient care, in order to facilitate patient satisfaction, clinic efficiency, and provider productivity.
The Clinic Registered Nurse is responsible to assess, plan, implement, and evaluate patient care, and work within a collaborative and cooperative relationship with other members of the healthcare team.
Registered Nurses plan and implement patient and family education.
The Nurse Practice Act and Administrative Rules of the state of Montana govern registered nursing practice.
Must possess the skills and abilities to engage in the nursing process including but not limited to the assessment, nursing analysis, planning, nursing intervention and evaluation in the promotion and maintenance of the patient's health across the continuum of life.
Must have the skills needed to supervise and delegate appropriate functions to subordinate personnel.
Must have the skills/abilities to evaluate and ensure that the medical plan of care is carried out.
Must have the educational, physical and mental capabilities to perform procedures common to their nursing unit.
Must complete department specific competency validation checklists within four (4) month probationary period or as designated per topic
Room patients - Gather patient data consistently and accurately, collect information on history of present illness or injury, obtain vital signs, review current medications and allergies.
Document patient encounters in EHR/paper chart.
Triage and respond to patient phone messages in a timely manner according to clinic guidelines, collaborate with provider, act on provider response, and communicate with patient; document task communications in EHR/paper chart.
Demonstrate safe performance of multiple nursing procedures according to policy/clinic guidelines and assist providers with clinic procedures.
Adhere to departmental guidelines on medications: may include injections, prescription refills, intravenous administration (after certification and competency validation), opioids.
Coordinate scheduling of appointments, referrals, s, procedures; track s and referrals.
Provide patient education/instructions and document in EHR/paper chart.
Coordinate care for walk-in patients, provide service recovery, assist with clinic quality activities. Other duties as assigned by Clinical Supervisor or Clinic Manager.
Collects Comprehensive data pertinent to the patient’s health or the situation (Assessment)
needs of the patient or situation
- Collects data in a systematic and ongoing process.
- Involves the patient, family and other healthcare providers in data collection
- Prioritizes data collection activities based on the patient’s immediate condition, or anticipated
Analyzes the assessment data to determine diagnoses or issues (Diagnosis)
- Uses evidence-based assessment techniques in collecting pertinent data
- Uses problem solving thinking
- Synthesizes available data, information and knowledge relevant to the situation to identify patterns and variances
Identifies expected outcomes for a plan individualized to the patient or the situation
- Derives the patient nursing diagnoses or issues based on assessment data
- Validates the nursing diagnoses or issues with the patient, family and other healthcare providers when possible and appropriate
- Documents nursing diagnoses or issues in a manner that facilitates the determination of the expected outcome or plan
Develops a plan that prescribes strategies and alternatives to attain expected outcomes (Plan of Care)
- Involves the patient, family and other healthcare providers in formulating expected outcomes
- Develops culturally appropriate expected outcomes for the diagnoses
- Develops expected outcomes that provide direction for the continuity of care
- Modifies expected outcomes based on changes in the status of the patient or evaluation of the situation
Implements the identified plan of care
- Develops an individualized plan of care considering patient characteristics or the situation
- Develops the plan in conjunction with the patient, family and others as appropriate
- Includes strategies within the plan that address each of the identified diagnoses or issues
- Provides for continuity within the plan
- Establishes plan priorities with the patient, family and others as appropriate
- Utilizes the plan to provide direction to other members of the healthcare team
Employs strategies to promote health and a safe environment
- Implements the plan of care in a safe and timely manner
- Documents implementation and any modifications to the plan of care
- Utilizes evidence-based interventions and treatments specific to the diagnoses or problem
- Collaborates with nursing colleagues and others to implement the plan of care
- Coordinates the implementation of the plan of care
- Documents the coordination of care
developmental needs, activities of daily living and preventative self-care.
- Provides health teaching that addresses such topics as healthy lifestyles, risk-reducing behaviors,
Systematically enhances the quality and effectiveness of nursing practice
- Seeks opportunities for feedback and evaluation of the effectiveness of health teaching strategies used
accountable, ethical manner.
- Demonstrates quality by documenting the application of the nursing process in a responsible,
>Identifying aspects of practice important for quality monitoring
- Uses the results of quality improvement activities to initiate changes in nursing practice
- Uses creativity and innovation in nursing practice to improve care delivery
- Incorporates new knowledge to initiate changes in nursing practice
- Participates in quality improvement activities, including but not limited to:
>Using indicators developed to monitor quality and effectiveness of nursing practice
>Collecting data to monitor quality and effectiveness of nursing practice
>Analyzing data to identify opportunities for improving nursing practice
>Formulating recommendations to improve nursing practice
>Implementing activities to enhance the quality of nursing practice
>Developing, implementing and evaluating policies, procedures and/or guidelines to improve the quality of practice
>Participating on interdisciplinary teams to evaluate clinical care
>Participating in efforts to minimize costs and unnecessary duplication
Attains knowledge and competency that reflects current nursing practice
Evaluates one’s own nursing practice in relation to professional practice standards and guidelines,
- Participates in ongoing educational activities related to appropriate knowledge bases and professional issues
- Demonstrates a commitment to lifelong learning through self-reflection and inquiry to identify leaning needs
- Seeks experiences that reflect current practice in order to maintain skills and competence in clinical practice or role performance
- Acquires knowledge and skills appropriate to the specialty area, practice setting, role or situation
- Maintains professional records that provide evidence of competency and life long learning
- Seeks experiences and formal and independent learning activities to maintain and develop clinical and professional skills and knowledge
relevant statutes, rules and regulations
>Provides age appropriate care in a culturally and ethnically sensitive manner
- The registered nurse’s practice reflects the application of knowledge or current practice standards, guidelines, statutes, rules and regulations
>Engages in self- evaluation of practice on a regular basis, identifying areas of strength,
as well as areas in which professional development would be beneficial
>Obtains informal feedback regarding one’s own practice from patients, peers,
professional colleagues and others
>Participates in systematic peer review as appropriate
>Takes action to achieve goals identified during the evaluation process
>Provides rationales for practice beliefs, decisions and actions as part of the informal and
formal evaluation processes
Interacts with and contributes to the professional development of peers and colleagues
care conferences or presentations at formal or informal meetings
- Shares knowledge and skills with peers and colleagues as evidenced by such activities as patient
- Provides peers with feedback regarding their practice and/or role performance
- Interacts with peers and colleagues to enhances one’s own professional nursing practice and/or
Collaborates with patient, family and others in the conduct of nursing practice
- Maintains compassionate and caring relationships with peers and colleagues
- Contributes to an environment that is conducive to the education of healthcare professionals
- Contributes to a supportive and healthy work environment
patient or situation
- Communicates with patient, family and healthcare providers regarding patient care and the nurses role in the provision of that care
- Collaborates in creating a documented plan, focused on outcomes and decisions related to care and delivery of services that indicates communication with patients, families and others
- Partners with others to effect change and generate positive outcomes through knowledge of the
Integrates ethical provisions in all areas of practice
- Documents referrals, including provisions for continuity of care.
- Delivers care in a manner that preserves and protects patient autonomy, dignity and rights
- Maintains patient confidentiality within legal and regulatory parameters
- Serves as a patient advocate assisting patients in developing skills for self advocacy
- Maintains a therapeutic and professional patient-nurse relationship with appropriate professional
- Demonstrates a commitment to practicing self-care, managing stress, and connecting with self and
Integrates research findings into practice
- Reports illegal, incompetent or impaired practices
>Identifying clinical problems specific to nursing research (patient care and nursing practice)
- Utilizes the best available evidence including research findings to guide nursing practice decisions
- Actively participates in research activities at various levels appropriate to the nurse’s level of education and position as opportunity affords
>Participating in data collection
>Participating in a formal committee or program
>Sharing research activities and/or findings with peers and others
>Critically analyzing and interpreting research for application to practice
>Using research findings in the development of policies, procedures, and standards of
practice in patient care
Provides leadership in the professional practice setting and the profession
- Engages in teamwork as a team player and a team builder
- Works to create and maintain healthy work environments
- Displays a commitment to life-long learning for self and others
- Teaches others to succeed by mentoring and other strategies
- Exhibits creativity and flexibility through times of change
- Demonstrates energy, excitement and a passion for quality work
- Willingly accepts mistakes by self and others, thereby creating a culture in which risk-taking is not only safe but expected
- Inspires loyalty through valuing people as the most precious asset in an organization
- Directs the coordination of care across settings and among caregivers including oversight of licensed and unlicensed personnel in any assigned or delegated tasks
- Serves in key roles in the work setting by participating on committees, councils and teams
- Promotes advancement of the profession through participation in professional organizations.
Bozeman Deaconess Hospital - 2 years ago