Clinic Behavioral Health Nurse – CMA/CNA

1. Performs admission and assessment activities for each patient prior to being seen by the provider according to the reason for the visit.

• Follows admissions and assessment guidelines check list (full set of vitals).
• Completes computer admission process.
• Measures all vitals, including weight blood pressure, pulse, temperature and documents in patient chart.
• Documents allergies and type of reaction.
• Conducts applicable assessments effectively (age appropriate).
• Recognizes any deviation from normal and reports to the Provider.
• Reviews and updates medication list at each visit.
• Maintains patient flow from waiting area to exam rooms and keeps patients informed of unexpected waits. Performs complete admission assessment.

2. Assists healthcare providers in accordance with Medical Assistant scope of practice.

• Collects and prepares specimens for lab tests.
• Handles instruments.
• Preps patients for procedures.
• Changes dressings, removes sutures and performs venipuncture.
• Prepares and administers medications as directed by a healthcare provider.
• Administers immunizations.
• Enters healthcare provider orders into the computer system, as needed.
• Collaborates with healthcare providers to coordinate medical and nursing management of patient care.

 3. Ensures exam rooms are stocked with adequate medical supplies, maintains instruments, prepares sterilization as required.

• Maintains all logs and required checks (i.e. refrigerator temperatures, emergency medications, expired medications, oxygen, cold sterilization fluid change, etc.)
• Inventories medical supplies and equipment.
• Reports any malfunctioning equipment.

4. Schedules appointments and tests; enters orders into the electronic health record according to orders from and at the direction of the providers.

• Ensures all related reports, labs and information is available in patient’s medical record prior to appointment.
• Pre-certifies patients for insurance coverage.
• Sets up referral contacts.

5. Performs emergency treatment as required in accordance within the Medical Assistant scope of practice.

• Initiates or assists in patient care in an effective and responsive manner as each situation requires.
• Triages each emergency situation appropriately and involves other resources as appropriate.
• Follows emergency policies, procedures and protocols in an effective manner.

6. Performs clinical administrative work.

• Triages patients over the phone using protocol to determine the acuity of the visit and the visit-length for scheduling purposes.
• Schedules appointments.
• Files charts.
• Processes medical billing.
• Transcribes dictation.

7. Performs and maintains documentation.

• Documents accurate and ongoing assessments of patient status that reflect nursing interventions, patient responses, patient teaching and status of outcomes at discharge.
• Completes shift end check prior to leaving duty.

8. Communicates effectively.

• Communicates and collaborates effectively with other health team members regarding patient condition, nursing plan of care, patient satisfaction needs and recommendations for meeting identified outcomes.
• Follows approved shift report format when communicating patient information.
• Identifies and recognizes abnormal symptoms/changes in patient condition, established priorities, and takes appropriate action. Appropriately reports condition changes to medical provider.

 9. Promotes and ensures patient and staff safety in all aspects of responsibilities.

• Administers medications, treatments and procedures in a timely and safe manner according to health care provider orders and nursing policy, including appropriate performance of standard precautions, using two patient identifiers, and performing patient risk assessments every shift.
• Utilizes proper body mechanics, transfer/lifting techniques to minimize fall risk to patient and injury to self.
• Implements infectious disease controls as appropriate including isolation procedures, proper use of hand washing and gloves.
• Follows proper procedures for wasting narcotics and disposal of sharps and hazardous materials.

10. Performs other duties as assigned.