Mid-Level Registered Nurse (SMB Outpatient) Job Description Template

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Conduct Patient Assessments: Perform initial patient intake and ongoing assessments, including measuring vitals, reviewing medical history, and documenting chief complaints each visit . Identify patient needs and level of care required, escalating urgent conditions appropriately.

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Administer Treatments & Medications: Safely administer medications (oral, injections, immunizations) and perform treatments such as wound dressings or IV infusions as ordered Follow the -five rights- of medication administration (right patient, drug, dose, route, time) and monitor for adverse reactions on-site.

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Assist in Procedures: Prepare patients and assist the physician or NP during minor surgical procedures, exams, or diagnostic tests conducted in the clinic (e.g. suturing, lesion removals, Pap smears). Ensure sterile technique and patient comfort throughout

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Patient Education & Counseling: Provide clear instructions and education to patients and families on care plans: e.g. explain medications and schedules, wound care at home, disease management strategies, and preventive health practices

. Verify patient understanding and readiness to follow the advice (teach-back).

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Care Coordination & Follow-Up: Coordinate referrals to specialists or external services when needed

. Arrange follow-up appointments or phone check-ins to monitor patient status.

Communicate with pharmacies on prescription refills and with labs for test results as necessary. Ensure continuity of care by relaying critical information to patients and the care team.

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Documentation & Records Management: Maintain meticulous and timely documentation in the electronic health record (EHR) for all patient interactions

. Chart assessments, nursing interventions, medications given, patient responses, and any changes in condition or provider orders

. Produce accurate care plans, progress notes, and visit summaries that meet compliance and quality standards (no omissions or errors).

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Quality and Safety Compliance: Adhere strictly to clinic protocols for infection control, medication storage, equipment sterilization, and waste disposal. Uphold patient safety by double-checking identifiers, allergy alerts, and informed consent. Proactively identify and correct potential safety issues (e.g. fall risks, equipment malfunctions) and report errors or incidents according to policy (no cover-ups).

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Team Collaboration: Work collaboratively with the healthcare team. Supervise tasks given to MAs or junior staff, such as obtaining EKGs or prepping exam rooms, and verify their completion and accuracy . Communicate effectively with providers - e.g. present patient cases, clarify orders - and with front-desk staff to optimize scheduling and patient flow. Step in to support colleagues during high volume or staffing shortages, maintaining a team-oriented environment.

-Clinical Assessment & Triage: Skilled in conducting head-to-toe assessments, recognizing normal vs. abnormal findings, and prioritizing care. Able to quickly evaluate symptoms in an ambulatory context to determine if immediate intervention or higher-level care is needed (e.g. identifying signs of stroke or anaphylaxis in a clinic patient). -Vital Signs & Basic Diagnostics: Proficient in measuring and interpreting vital signs (BP, pulse, respirations, O₂ sat, temperature) and point-of-care tests (blood glucose checks, rapid strep tests, urine dipstick, etc.). Can recognize when readings are outside normal ranges and respond appropriately. -Medication Administration: Sound knowledge of pharmacology basics and injection techniques. Able to calculate dosages and prepare medications accurately (especially common outpatient meds and vaccines)

. Follows proper routes (IM, subcutaneous, oral, etc.), needle sizes, and safety protocols (e.g. needle disposal). Uses eMAR (electronic Medication Administration Record) or logs to document each dose given. -Electronic Health Records (EHR) Proficiency: Adept at using common clinical software systems to document encounters, update patient records, and retrieve data. Familiar with scheduling and e-prescribing modules. (Common SMB EHRs include Athenahealth, eClinicalWorks, Kareo/Tebra, or Practice Fusion - known for intuitive interfaces combining charting, billing, and scheduling .) Able to maintain electronic health records, enter orders, and navigate patient portals efficiently -Clinical Procedures: Capable of performing routine nursing procedures in-office: e.g. starting peripheral IVs or IV infusions if needed, drawing blood, administering oxygen, performing ECGs, basic wound suturing removal, catheterizations, and sterile dressing changes. Understands proper technique and infection control for each. -Infection Control & Safety: Rigorously follows infection control practices (hand hygiene, PPE use, instrument sterilization). Knowledgeable about standard precautions and clinic sanitization. Can educate patients on infection prevention (e.g. wound care or COVID-19 protocols)

. Maintains current Basic Life Support (BLS) certification (and ACLS if required), ready to initiate CPR or first aid during emergencies. -Care Planning & Documentation: Able to develop basic nursing care plans for common outpatient

-Communication: Exceptional communication skills - listens actively to patients and colleagues and conveys information clearly . Explains medical information to patients in understandable, empathetic terms (avoiding jargon). Adjusts communication style for different audiences (e.g. children vs. adults, patients with language barriers). Writes coherent, professional emails/EHR messages. -Empathy & Compassion: Demonstrates genuine care and patience with patients. Puts themselves in the patient-s situation to understand their feelings

. Offers emotional support, reassurance, and respect, especially when patients are anxious or in pain. Maintains a calming presence and does not become frustrated with difficult patients; instead seeks to understand concerns (high emotional intelligence). -Teamwork & Collaboration: Highly cooperative and team-oriented

. Works well with multidisciplinary staff - from physicians to front-desk - to achieve common patient care goals. Willingly assists coworkers when own tasks allow, and communicates openly to resolve conflicts. Dependability and reliability are evident: others trust this RN to follow through on tasks and be available to help -Problem-Solving & Critical Thinking: Strong critical thinking skills to analyze situations and make sound decisions quickly

. In a fast-paced clinic, can adjust when things don-t go as planned - e.g. troubleshooting equipment issues or finding alternative solutions if a provider is running late. Uses good judgment to decide what can be handled independently vs. what needs provider input (does not hesitate to escalate truly urgent issues). -Attention to Detail: Meticulous and detail-oriented in all aspects of work

. Double-checks documentation for accuracy, notices subtle changes in patient conditions, and catches errors (like a dosage discrepancy or an allergy alert) before they cause harm. Maintains organized records and an orderly workspace to prevent mistakes. -Time Management: Excellent ability to prioritize and manage time

. Can juggle multiple patients and tasks - e.g. rooming one patient while monitoring another-s lab result - without forgetting steps. Prioritizes critical tasks (like urgent triage or medication administration) and stays efficient with routine chores (paperwork, stocking supplies) so that everything is completed by end of day. Uses tools (checklists, scheduling) to stay on track. -Adaptability: Embraces change and remains flexible in dynamic situations

. Adapts to last-minute schedule changes, new clinic protocols, or unexpected staff shortages with a can-do attitude. Handles a varied patient population and shifting priorities without becoming flustered. Able to learn new technologies or procedures quickly. -Professionalism & Ethics: Maintains a high standard of professionalism, even under stress

. Respectful to all patients (culturally sensitive and non-judgmental) and to coworkers. Upholds nursing ethics - honesty, patient confidentiality, and advocacy. Accepts responsibility for mistakes and seeks to correct them rather than blame others. Engages in continuous learning to improve skills and stay current, demonstrating accountability for one-s professional growth.