719 Best medical records Jobs in San Antonio, Texas (October 2025)

San Antonio Behavioral Healthcare Hospital

Transfer Intake RN (variable shifts)

25 days ago

San Antonio

Job Description To assess the needs of walk-in clients and phone callers and ensure their referral to the service or resource to best address those needs and delivering quality general/psychiatric nursing care to patients who are hospitalized for treatment of psychiatric or emotional disorders; to support the hospital and program philosophy of care; to ensure the safety and well-being of each patient. The Psychiatric RN will provide professional nursing care to patients according to hospital policy and procedure; will assess patients, their care needs, plan and implement nursing care procedures, evaluate patient progress and modify care plans as necessary; will provide teaching to patients and their families; will direct the work of nursing support staff through the use of appropriate delegation and supervision skills. Essential Duties: • In house assessments are completed with treatment referral recommendations made and documented; use the approved admission criteria and make decisions concerning the level of care for treatment using the least restrictive level appropriate. The plan for episode of care is initiated at admission to all levels of care., • Assists clinicians, administration and physician in the assessment of pending admits, • Plans, coordinates, and evaluates direct and indirect facility assessments and client admissions, • Ensures admission paperwork is completed in accordance with hospital policy, • Ensures the care and treatment of the patients are rendered in a competent manner and are based on current developmental theory and psychiatric nursing knowledge and standards; care is evaluated against the goals and plan of care and is revised periodically, as appropriate., • Plans and provides nursing care for patients through a systematic process of interaction with patients, the patient's significant others, and the appropriate health care providers, collects and analyzes data regarding the patient's physical, psychosocial, environmental, self-care, educational, spiritual, cultural, and anticipated discharge needs., • Ensures each patient's unique needs are identified and incorporated into a comprehensive, individualized care plan including the severity of the disease, condition, impairment/disability as important elements of the plan., • Provides direct care to patients, which includes facilitating social and emotional needs, supervising medication schedules, evaluating patient progress and patient's access to the appropriate level of care and setting., • Collaborate with interdisciplinary professionals to determine and provide the best possible care for patients., • Provides social support for patients by creating and encouraging patients to take advantage of opportunities such as support groups, social activities and other therapeutic measures., • Conducts intake assessments through interviews with patients and relatives to gather case history., • Makes nursing diagnosis of the medical and emotional status of patients and recommends treatment options., • Consults with psychiatrists and other behavioral health staff in designing appropriate treatment plans for clients., • Maintains accurate records and documentation of patient treatments, immunizations, laboratory results, notes reactions to psychotropic drugs and other medications, written charts, patient activities and progress according to standard medical record keeping and hospital policy and procedures., • Assists the client in understanding the nature of emotional disturbances and accepting the need for treatment., • Complies with laws, rules, regulations, protocols, and procedures., • Uses professional judgment to ascertain and to apply appropriate intervention techniques with patients in crisis, • Assists in maintaining a safe and secure environment for staff and patients., • Tests for vital signs of pain and ensures treatments of pain and arranges further medical attention when necessary., • Performs administrative tasks such as filing, answering phones and computer entry of progress notes., • Organizes the activities and schedules for medical and/or non-medical tasks of the Child, Adolescent and Adult and support staff for a given shift., • Maintains patient confidentiality. Job Requirements Must be 21 years old or older Education - RN, ADN or BSN from an accredited college or university. Experience – Minimum of 2 years clinical experience, preferably in a behavioral healthcare setting, phone triage, tele-health or case management or combination of education and experience. Basic teaching and training skills a plus. Required Licenses - Valid Texas RN license in good standing required. CPR (must be obtained within 30 days upon hire) BLS, ACLS, CPI certifications a plus. Additional Requirements: Must pass a medication administration exam before administering medications. Must obtain and maintain approved CPR certification as well as successful completion of Management of Assaultive Behavior training including restraint and seclusion policies prior to assuming patient care responsibility. Knowledge Skills and Abilities • Knowledgeable of patient rights and laws pertaining to mental health and regulations pertaining to psychiatric nursing and the treatment of the mentally and emotionally disturbed patients. Theories, principles, and techniques of group and individual psychotherapy. Symptoms and behavior patterns of emotionally disturbed mentally ill patients., • Advanced knowledge and clinical skills in diagnosis and treatment of mental health, professional nursing principles, procedures, and techniques used in the care and treatment of psychiatric patients, social, psychological, and physical factors of mental and emotional disorders., • Knowledgeable of medical and psychological terminology, medications, including psychotropic drugs, and effects on psychiatric patients as well as control, preparation and administration of medications., • Displays basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crises intervention practice, medical and psychiatric emergency procedures., • Basic knowledge of abnormal psychology as typically found in the child or adolescent psychiatric population, application of this knowledge to child, adolescent or adult knowledge of medical terminology, especially those terms associated with child, adolescent or adult psychiatric care; thorough familiarity of psychopharmacy and the use of psychotropic medications with child, adolescent or adult psychiatric population, basic teaching and training skills helpful; problem-solving; organizational and time management; crisis intervention skills, • Ability to apply professional nursing care principles and procedures in the evaluation and treatment of psychiatric patients. Develop interpersonal therapeutic relationships with psychiatric patients., • Communicate effectively with a variety of individuals and function calmly in situations, which require a high degree of sensitivity, tact, and diplomacy., • Ability to exercise appropriate judgment in answering questions and releasing information; analyze and project consequences of decisions and/or recommendations., • Ability to handle confidential information with great sensitivity., • Well-developed verbal and written communication skills in English. Skill to communicate effectively in order to exchange and/or provide information, build and/or maintain cooperative relationships., • Ability to effectively interact with persons of widely diverse roles, backgrounds, cultures, and socio-economic classes, those in crises or resistant or negative toward organization., • Displays basic knowledge of treatment procedures; interventions common to acute psychotic as well as non-violent crises intervention practice., • Basic knowledge of abnormal psychology as typically found in the child or adolescent psychiatric population, application of this knowledge to child, adolescent or adult knowledge of medical terminology, especially those terms associated with child, adolescent or adult psychiatric care., • Skilled in facilitating and/or co-facilitating process-oriented and didactic groups., • Skilled in problem solving, prioritizing and time management Perform the following with or without reasonable accommodations: • Ability to stoop, kneel, crouch, crawl, reach, stand, walk, push, pull, lift, grasp, and be able to perceive the attributes of objects such as size, shape, temperature, and/or texture by touching with skin, particularly that of the fingertips., • Ability to express and exchange ideas via spoken word during activities in which they must convey detail or important spoken instructions to others accurately, sometimes quickly and loudly., • Hearing to perceive the nature of sound with no less than 40 db loss @ Hz, 1000 Hz, and 2000 Hz with or without correction; ability to perceive detailed information orally and make fine discriminations in sound., • Perform repetitive motions with wrists, hands, and fingers. Individual must be able to exert up to 100 pounds of force occasionally and to be able to lift, carry, push, pull, or otherwise move objects., • Work requires a minimum standard of visual acuity with or without correction that will enable people in the role to complete administrative and clerical tasks, as well as inspect and analyze., • Must be able to work and concentrate amidst distractions such as noise, conversation and foot traffic; ability to handle interruptions often and be able to move from one task to another, • Health Insurance, • Vision Insurance, • Dental Insurance, • 401K Retirement Plan, • Healthcare Spending Account, • Dependent Care Spending Account, • PTO Plan with Holiday Premium Pay, • Life Insurance (Supplemental Life, Term, and Universal plans are also available.), • Short and Long-Term Disability (with additional buy-in opportunities)

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