RN Behavioral Health / Behavioral Health Crisis Assessment

• Conducts individualized age-specific patient/family assessments according to defined unit scope and nursing practice standards, appropriate collaborative problems (CPG's)/nursing diagnoses (ND's), or protocols. (Individualized refers to the patients developmental, cognitive, cultural, psychosocial, spiritual, and educational/family influences and physical/medical care needs.) 
• Admission/Initial Assessment: 
  • Collects and documents data related to patients individualized care. 
  • Demonstrates age-specific competency in assessment of patients by the ability to obtain and interpret information in terms of the patient needs, knowledge of growth and development, and understanding of the range of treatment needed by these patients. 
  • Assesses patient/family need for education and uses an individualized approach in delivery style. 
  • Assesses family expectations for, and involvement in the assessment and continuous care or treatment of the patient. 
  • Identifies nursing diagnoses, collaborative problems, and/or protocols for each patient, based on assessment, at the time of admission. 
• Shift Assessment/Reassessment 
  • Performs reassessment based on unit standards, CPG's/ND's, protocols and changes in patient condition. Communicates changes to appropriate persons (MD, Charge RN, family) as indicated. 
  • Utilizes appropriate telephone etiquette.
• Develops individualized patient/family plan of care using CPG/NDs, and practice guidelines/protocols to meet identified needs in collaboration with Behavioral Health Team. (Plan of Care includes current and anticipated actions focused on care, education, discharge needs.) 
  • Utilizes assessment data from the healthcare team to individualize appropriate goals and actions for the patient, including collaboration with the family and the healthcare team. 
  • Utilizes individualized assessment data to develop the patient/familys plan of care. 
  • Formulates goals and outcomes based on assessment data. 
  • Revises plan of care based on patients condition, interdisciplinary input, and family needs. 
  • Demonstrates ability to prioritize patient interventions based on assessments/reassessments
• Implements and evaluates nursing actions in accordance with the individualized patient/family plan of care and patient condition/needs. 
  • Oversees that the nursing and interdisciplinary plan of care/goals are coordinated, implemented, evaluated, and revised as needed. Identifies the need for interdisciplinary involvement/outside resources and follows through. Uses appropriate resources (Charge Nurse, CNS/Educator, Director, MD, etc.) to ensure that clinical outcomes are achieved. 
  • Incorporates critical thinking into the delivery of clinical skills and in analyzing patient response to orders, tests, labs, medications, and treatments. 
  • Demonstrates clinical competence in administering interventions according to identified standards and age specific needs. 
  • Provides and/or coordinates with other disciplines patient/family education according to identified care needs, considering assessment of patient/familys readiness to learn
• Documentation reflects accurate assessment/evaluation, modification, and patients response to therapy, changes in condition, and therapeutic interventions/procedures. 
  • Entries in the medical record follow hospital policy (i.e., date, time, use of appropriate abbreviations, and legibility). 
  • Documentation is completed within established timeframes including, but not limited to: Admission Assessment form, daily Patient Flowsheet, Family Education Record, and Interdisciplinary Goals. 
  • Reviews and updates computerized care plan to accurately reflect the plan of care. 
  • Completes computerized documentation within established timeframes, including, but not limited to: Medication Administration Record, Allergies, Patient Information, etc. 
  • Completes and verifies accurate order entry in the computerized care plan. 
  • Ensures that discharge instructions clearly state patient care needs after discharge.
• Uses clinical judgment based on nursing skills acquired through formal and informal experiential knowledge and evidence-based guidelines to globally assess the patient's situation 
  • Supports staff in providing a safe environment for patients with high-risk behaviors by inspecting rooms, proactively identifying potential safety hazards, and removing at-risk items. 
  • Delivers competent and skilled nursing care to patients and families according to their identified needs. 
  • Provides content expertise and education to staff caring for high-risk patients and assists staff in finding available resources related to behavioral health patients. 
  • Provides a just in time resource to nursing, administrative supervisors and physicians caring for high-risk behavioral patients. 
  • Assists staff in finding available resources related to behavioral health patients. 
  • Reviews documentation and orders in EPIC and collaborates with staff to ensure that the patients level of observation is appropriate, and documentation is accurate and complete. 
  • Identifies patient care concerns in real time and collaborates and escalates as needed to promote resolution. 
  • Provides education and facilitates learning for the patient care team related to constant visual observation guidelines and policies, therapeutic interactions, and patient safety. 
  • Assists with consistent application of guidelines and policies across the hospital. 
  • Identifies and presents opportunities for performance/quality improvement activities to improve clinical outcomes. 
  • Assists with patient de-escalation, provides physical intervention if needed, thorough and accurate documentation, and participates in the debriefing afterwards.
  • Audits Physical Intervention documentation and assists in collecting, inputting, and sharing data in real time. 
  • Delivers care with a team-oriented approach, an emphasis on good customer relations, sound clinical judgment, and appropriate decision-making abilities that take into consideration evidence-based practice. 
  • Advocates for the patient, represents the concerns of the patient/family and identifies and assists in resolving concerns. Ensures that Patient Health Information (PHI) is protected and secured at all times. 
  • Adheres to all infection prevention initiatives (i.e., hand hygiene, proper disposal of waste, etc.)

Education Qualifications

• Associate's Degree from an accredited school of nursing Required or
• Bachelor's Degree from an accredited school of nursing Required

Experience Qualifications

• 2 years of psychiatric nursing experience Preferred and
• Experience with pediatric patients Preferred and
• Previous experience with EPIC Preferred

Skills and Abilities

• Must be able to perform a variety of duties, often changing from one task to another of a different nature, without loss of efficiency or composure, and be able to perform under stressful conditions when confronted with multiple requests, demonstrating prioritizing skills.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the state of Nebraska Upon Hire Required and
• BLS - Basic Life Support through the American Heart Association Upon Hire Required and
• PALS - Pediatric Advanced Life Support within 180 Days Preferred

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