LPN - Mills

Primary Purpose: To provide safe high-quality patient care while following all standards of care and regulatory requirements. To provide timely and accurate documentation to assist in billing of services and ensure a complete medical record. To provide Patient and family education.  To ensure patient satisfaction by providing the highest level of customer service, assisting in identification and implementation of strategic initiatives in accordance with hospital mission, vision and values.

Formal Policy-Setting Responsibilities: Formally responsible for making recommendations regarding policies associated with the job's purpose and essential responsibilities.                                 

Routine Decision Making: Determine patient/ physician needs and act accordingly. Determine appropriate patient scheduling, while meeting the needs of urgent patients. Collaborate with team as appropriate to determine patient criteria such as records and insurance have been met. Review for appropriate referrals and ensure patient education.  Review opportunities for process improvements.   

Formal Supervisory Responsibility: No formal supervisory responsibility.                                               

Unusual Working Conditions: Risk of blood, body fluid contamination. Potential exposure to hazardous drugs and chemicals.           

Age Specific Competencies: Provides care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

Essential Responsibilities and Tasks

Implementation of plan of care for all assigned patients daily. (60% of time)                      

• Requests and obtains required records are received.  Enters chart preparation prior to patient arrival.      

• Prepares rooms prior to each visit, sets up appropriate equipment if applicable, cleans rooms before and after each patient and end of day.

• Reviews and updates patient history and reason for visit at each visit. Obtains test results and other documentation. 
• Identifies the patient using the 2 approved patient identifiers prior to all patient care including administration of medication or collection of specimens.                             
• Documents vital signs to include weight, height, blood pressure, pulse, and temperature at each visit.  Documents pain level and other required assessments at each visit including medication reconciliation.                                  
• Documents and reports all critical vital signs and critical test results to the ordering provider per hospital policy and implements further orders immediately. Documents details in the patient record.        
• Ensure accuracy and completion of the medical record in collaboration with the provider- check medical record for inconsistencies, notify provider and check to ensure the inconsistencies are resolved.
• Maintains patient care documentation logs as assigned per clinic/provider and regulatory agencies.
• Assist providers with documentation assistance as applicable.     
• Places orders and medications as ordered by provider through Meditech.
• Provides education to the patients and family including but not limited to tests, office procedures, discharge instructions and follow up process.
• Obtains consent when indicated.
• Administers medication and documents within the chart to include medication name, NDC number, lot number, expiration date, quantity, site, route and all other required fields be completed within chart.
• Maintain confidentiality and privacy of information in accordance with HIPAA regulations and organizational policies.
• Review to ensure that continuum of patient is care is met.

Actively participates in clinic operations. (10% of time)                                                 

• Orders supplies and special-order supplies to maintains appropriate levels of inventory for effective patient cost containment. 
• Responsible for care (cleaning and storage) of equipment following all manufacturer instructions for use (IFU) for user cleaning and equipment.             
• Reports all emergent problems to manager. Tags and removes malfunctioning patient care equipment immediately and complete work requisition.                                        

• Completes monthly quality checks as assigned.  Enters appropriate repair tickets as indicated and follows up to ensure completion. 

• Assist in orientation and training of new staff. 
• Keeps clinic clean and clutter free.           
• Other assignments as indicated.                                

Assists provider with procedures if indicated. (5% of time)

• Appropriately prepares rooms prior to each patient visit, obtaining equipment and instruments.
• Confirms consent has been obtained if required prior to the procedure.                                                 
• Identifies the patient by using the two approved patient identifiers prior to procedure or medications.
• Document in the medical record as indicated.     
• Effectively communicate discharge instructions to patient and responsible party at the time of discharge. 

Manages telephone calls, faxes, and messages. (10% of time)                                                    

• All telephone calls are returned in a professional manner and documented by the end of the shift. All patient phone calls are documented in the medical record.                                           
• All telephone calls, faxes, and messages are carried out per provider's instructions, and documented in the medical record.
• Assist in scheduling of patient appointments and testing. 
• Scanning of medical records in the chart.
• Assisting prior authorization personnel to reduce any delays in scheduling or medication receipt for the patients.  

Develops and promotes performance improvement initiatives. (10% of time)                                    

• Plans, develops and evaluates self-objectives at a minimum annually.                                                       
• Routinely looks for opportunities to make improvements in the department.       
• Works with team and participates in implementing planned changes and activities. 
• Performs ongoing evaluation of changes, determine needed changes, discuss with stake holders and then implement updated changes to improvement.
• Attends department staff meetings.

Other duties as assigned. (5%)

• Other duties as assigned within the scope of practice.

Education and Certification/ Registration Required for the Position: Technical or vocational school education with current LPN license in the State of Missouri; BLS required.                   

Required Knowledge: Knowledge of nursing skills; venipuncture; patient triage; pharmaceuticals; operation of equipment; insurance company requirements, disease processes, regulatory requirements, and prior authorization process/ICD10 codes.    

Required Skills and Ability: Organization and Problem-solving skills. Effective and professional interpersonal communication skills.  Ability to multi-task and prioritize patient assessment and nursing care.  Ability to work independently and as a team. Use of critical thinking skills to identify, analyze and prioritize issues. Assist in identification of solutions in collaboration with others.