Location: Madera,CA, USA
Responsibilities POSITION SUMMARY Conduct and document the complete Nursing Assessment, including an admission summary and nutrition assessment (not to exceed 48hrs). Identify, document and prioritize mental/medical problems, including the need for detoxification as appropriate. Initiate the Initial Multidisciplinary Treatment Plan, noting Initial Diagnosis, Psychiatric/Psychosocial problem (minimum of 1) and obtain patient's signature if applicable. Inventory Patient's Home Medication with patient's signature and notify House Supervisor to retrieve for patient lock-up until discharged. Initiate Close Observation (CO) forms. Responsible for the timely processing of inquiry and referral calls. Responsible for coordination of all admissions processes and serves as liaison to referral sources, families, payors, physicians, unit and hospital personnel involved with each admission. Respond to crisis calls and referrals with sense of urgency, verify insurance, triage patients, complete assessments, ability to staff clinical effectively, enter calls and admissions in computer and complete all admission paperwork with patient. Effectively communicate with unit staff and assist patient to unit. Pre-cert with payor source. Follow hospital's policies and procedures regarding admissions.Customers ServedPatients, families, medical staff, allied health professionals, other hospital department staff and external individuals requesting information. QUALIFICATIONS Education: Graduate from an accredited program of professional nursing required; Bachelor'sDegree preferred. Experience: 1-3 years of experience preferred in psychiatric health care. Working knowledge of DSM-V diagnostic criteria, mental status exam, and addiction and recovery field. Licensure: Currently licensed to practice by the California State Board of Nursing. Additional Requirements: CPR certification and successful completion of Crisis Prevention Intervention (CPI) training. CPI Training may be obtained during new hire orientation.Knowledge/Skills/Abilities: Excellent communication skills, i.e., verbal and written. Ability to prioritize duties as to need and urgency; work well under periods of high stress and pressure. Ability to multi-task and demonstrate critical thinking skills. Demonstrates an understanding of funding entities. Thorough knowledge of psychiatric services provided by the hospital. Ability to work flexible hours. Requires a basic understanding of computers; and accurate data entry skills. Knowledge of insurance contracts and payors. Knowledge of precertification for inpatient hospitalization. Experience gathering and documenting medical and clinical information to assess and staff appropriately with physician. Ability to triage for medical and psychiatric needs. Working knowledge of DSM-V diagnostic criteria, mental status exam, and addiction and recovery field Qualifications STANDARDS OF PERFORMANCE THE ESSENTIAL JOB FUNCTIONS ARE CATEGORIZED UNDER THE JOINT COMMISSION STANDARDS OF PERFORMANCE. Essential Functions: Comply with all Administrative, Clinical, and Human Resources policies and procedures. Actively supports the mission, philosophy, and goals of the hospital. Communicates with sensitivity to growth, development, and cultural issues. Receives and reviews referral/inquiry calls and responds to request for information, assessment and possible admission. Able to effectively serve and work with patients, families, referral sources, community resources as well as departmental and facility co-workers and management team. (heads) Provides and documents thorough and accurate assessment of individuals seeking admission. Assures accurate information is provided to referrals as requested. Works with referral source to ensure necessary patient clinical and medical information is received for the physician to make appropriate admission decisions. Receives physician's order to admit, as required per facility policy. Enters data into facility electronic systems, to include inquiry calls, referrals, and admissions. Collaborates with Business Office staff to ensure that payor information is obtained and verified. Performs assessments and medical screenings. Collaborates with clinical referral sources, families, doctors, agencies, and other callers to ensure assessments and/or admissions are coordinated in a timely fashion. Effectively monitor and address patient/family needs within the department as well as any medical issues. Ability to effectively address at risk, emotionally disturbed or in crisis potential patients and individuals effectively both over the telephone as well as in person. Ensure all referral patient medical record information is completed and nursing and clinical staff are adequately apprised of the patient's condition/history. Completes the administrative paperwork, including consent and releases to ensure that patients are fully informed during the admission process. Working knowledge of the state's Involuntary process and procedure Enter calls and admissions into computer and complete admission process appropriately. Maintains professional demeanor in dress, attitude, support of unit milieu, and hospital mission and philosophy. Other duties as assigned. Environmental Conditions: Exposure to psychiatric patients who may exhibit violent/aggressive behavior. Potential for exposure to communicable diseases; blood/body fluids; and other hazardous waste. General hospital and office environment.Diverse Age Groups Developmental Knowledge/ Specialty Programming : Specific Standards for the Care of Child Patients Ages 5 through 11 Maintain knowledge of the Child Program rules, protocols and handbooks guidelines. Maintain knowledge of children's stages of development and seek guidance from the nurse in charge when questions about the norms for behavior related to child development arise. Assess patients for behaviors consistent with the developmental stages and make note of any deviations in behavior. Recognize acting out behavior of child specific age group and set appropriate limits in clear, concise, behavioral and non-judgmental terms based on the age of the patient. Demonstrate an awareness of learning disabilities and translates treatment/program expectations to the learning-disabled child. Relate to child patients in an age-appropriate manner. Utilize seclusion and restraint procedures with an understanding of the need for modification in regard to smaller body sizes of children, abandonment issues and the history of physical and/or sexual abuse issues. Act as a resource to other staff in regard to the Child Patient Programs. Specific Standards for the Care of Adolescent Patients Ages 12 through 18 Maintain knowledge of the Adolescent Program rules, protocols and handbooks guidelines. Assess patients for behaviors consistent with the developmental stages and makes note of any deviations in behavior. Recognize acting out behavior of adolescent specific age group and set appropriate limits in clear, concise, behavioral and non-judgmental terms based on the age of the patient. Demonstrate an awareness of learning disabilities and translates treatment/program expectations to the learning-disabled adolescent. Relate to adolescent patients in an age-appropriate manner. Utilize seclusion and restraint procedures with an understanding of the need for modification in regard to smaller body sizes of adolescents, abandonment issues and the history of physical and/or sexual abuse issues. Act as a resource to other staff in regard to the Adolescent Patient Programs. Specific Standards for the Care of Adult Patients Ages 19 through 64 Gather information from the patient, family and interdisciplinary team and use judgements based on knowledge of adult behaviors in treatment planning and interventions. Recognize behaviors and set appropriate limits in clear, concise, behaviors and non-judgmental terms. Utilize seclusion/restraint procedures applicable to adult body size and past history of violent or emotional behaviors and/or history of physical and/or sexual abuse issues. Maintain current knowledge of the Adult Program rules, protocols and handbook guidelines. Utilize theoretical concepts to guide the effective practice of adult care within Specific Standards of Care for this age group. Specific Standards for the Care of Geriatric Patients Ages 65 and older Maintain knowledge of the developmental tasks and sociological theories of aging. Utilize theoretical concepts to guide the effective practice of gerontological health care and behavioral care. Gather the appropriate information from the patient, family and interdisciplinary team and use therapeutic judgements based on knowledge of gerontological health/behavioral care practices to develop a comprehensive plan of care. Utilize interventions based on gerontological theory to restore patients' functional capabilities and to prevent complications and excess disability. Maintain a complete knowledge of treatments, medications and side effects of such in the geriatric age group. Specific Standards for the Care of Chemically Dependent Patients Assesses patient needs as related to chemical dependency and document the plan of care from the admission through discharge. Collaborate with other chemical dependency staff professionals in planning for discharge and follow-up care. Maintain an awareness of how personal issues relating to co-dependency can impact work performance/relationships. Recognize and establish limits on medication-seeking behaviors. Exposure Categories:Blood born disease exposure category: IIOther potential hazard(s): Participates in therapeutic crisis intervention that involves some personal risk when dealing with physically aggressive patients.Job Classification: Hours based on departmental and facility needs may include day, evening and weekend hours. This job description in no way states or implies that these are the only duties to be performed by this employee. Employee will be required to follow any other instructions and to perform any other duties as requested by the Director of Admissions. Note: The essential job functions of this position are not limited to the duties listed above. KNOWLEDGE. SKILLS. AND ABILITIES THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND ABILITIES AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MA Y NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED FOR THIS POSITION. Knowledge of psychiatric and medical nursing procedures is essential. Knowledge of all code procedures. Knowledge of Mental Health Laws and Child Abuse/Neglect/Maltreatment laws, and the DHS provider agreement as applicable. Skill in organizing and prioritizing workloads to meet deadlines. Skill in telephone etiquette and paging procedures. Effective oral and written communication skills. Ability to communicate effectively with patients and co-workers. Ability to adhere to safety policies and procedures. Ability to use good judgment and to maintain confidentiality of information. Ability to work as a team player. Ability to demonstrate tact, resourcefulness, patience and dedication. Ability to accept direction and adhere to policies and procedures. Ability to recognize the importance of adapting to the various patient age groups to which assigned (ranging from preschool to geriatrics). Ability to work in a fast-paced environment; Ability to meet corporate deadlines. Ability to react calmly and effectively in emergency situations. PHYSICAL, MENTAL, AND SPECIAL DEMANDS MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE BYCASE BASIS. Ability to sit and stand (one-third of the shift) and walk (two-thirds of the shift). Ability to reach above, at or below waist height, kneel, bend, stoop, turn, twist, and throw(occasionally to frequently). Ability to see well enough to read charts, treatment plans and typewritten materials. Ability to hear well enough to detect noises on the unit and have the ability to discern odors. Ability to frequently lift and carry 10 lbs.; occasionally 20-50 lbs. Ability to frequently push/pull wheeled carts from 100-200 lbs. Ability to manipulate small and large tools (electric thermometer, telephone, wheelchair, bloodpressure cuffs, walkers, paper punch, addressograph, restraints, staplers, EKG machine, copymachine, etc.) Ability to spend 95% of the work day inside in temperatures varying from 60°-90° F., where noiselevels range from low to high and the ability to spend 5% of the work day outside in temperaturesvarying from 30°-110° F. Ability to frequently handle hazardous/infectious waste. Ability to work in an environment where chemicals are frequently used for cleaning, where mechanical and electrical hazards may occasionally be present and where dust, mist and steam are frequently generated in housekeeping tasks. Ability to work at a rapid pace and perform a variety of repetitive duties. Ability to respond to exposure to blood and body fluids.