I. RESPONSIBILITIES TO THEPATIENT

A. Initiatesan on-going systematic assessment of the physical, emotional, social,educational, and functional needs of the patient/family through interview,observation, and physical examination.

1. Receivesadmissions and/or transfers to the unit.

2. Completesnursing admission notes within 24 hours.

B. Interpretsassessment data and information to develop a nursing care plan which containsproblem identification, nursing diagnosis, nursing orders, approaches,interventions, short/long term goals, and discharge planning.

1. Developsnursing care plan utilizing nursing diagnosis

2. Assessessafety and fall risk levels for patients

C. Teachesand counsels patients/families, and makes referrals to appropriate resourcepersonnel when needed.

1. Documents patient, family, and significantother teaching

D. Participates as a productive member of the interdisciplinary team in assessment, planning, implementation andevaluation of rehabilitation goals.

E. Assuresthat medical orders are transcribed and processed accurately, andintegrates the medical care plan into the provision of nursing care.

F. Assures that medication/I.V. administration iscorrect and according to the established nursing policies andprocedures.

1. Looks up unfamiliar medications

2. Processesmedication orders

3. Administersmedications as ordered

4. Evaluateseffectiveness of PRN medications

5. Verbalizesprocess for self-administered medications

6. Verbalizespatient education on identified medications

7. Verbalizesstanding orders

8. Verbalizespolicy and procedure for maintenance and care of central line catheters

9. AdministersI.V. drugs

G. Providesfor personal and environmental safety in accordance with hospital and nursingpolicies and procedures

H. Demonstratesskills in handling emergency and life-threatening situations

1. Locates and uses crash cart items

2. Calls Code Blue and Medical Emergency

3. Initiates CPR

4. Follows P&P and POLST

I. Assuresthat documents in the medical record are complete, factual, accurateand timely.

1. Documentsmaterials and equipment used.

2. Verbalizesmethod to noting orders.

3. Documentsdischarge in chart.

4. Initiatesand updates care plan as appropriate.

5. Providesdischarge instructions.

6. Completesinteragency transfer form.

J. Providesnursing care to meet patient needs:

1. Performsa complete head-to-toe assessment of each assigned patient per shift usingproper documentation tools.

2. Actspromptly on changes in patient condition, utilizing SBAR method

3. Reviewslab and test results, notifying physician of abnormal and critical results

4. Performswound care in accordance with policy, utilizing proper documentation tools.

5. Performsbasic ventilator management and trouble-shooting.

II. RESPONSIBILITIES TO UNITSTAFF

A. Providesdirection and leadership in patient care to assigned personnel.

1. Actsas a team leader.

2. Makesassignments for team.

B. Prioritizesactivities and plans for effective use of time and staff in meeting patientneeds.

C. Communicatesthe plan of nursing care for each patient through reports, conferences, rounds,and patient care records.

1. Shift to shiftreport and shift huddle with aides

2. Delegates tasks to aides; monitors to makesure delegated tasks are completed appropriately.

D. Demonstratesresponsibility for the teaching of staff in areas of new techniques,policies and procedures.

1. Preceptor

E. Participatesin the quality improvement activities of nursing.

1. Attends appropriate meetings.

F. Communicatesidentified learning needs of self and others to the DON/CNO.

G. Assiststhe DON/CNO in the orientation of new staff.

H. Adheresto established policies and procedures of the hospital and NursingDepartment.

I. Activelyparticipates on nursing committees.

J. Performsother duties as assigned or requested.

III. RESPONSIBILITIESTO SELF

A. Evaluatesown performance and seeks opportunities for growth and

expansionof skills

B. Takesinitiative in upgrading and maintaining skills necessary to provide

qualitycare to patients and leadership to assigned staff.

C. Acquirescontinuing education sufficient to maintain licensure and certification

1. Maintains current nursing licensure

2. Provides Human Resources and DON/CNO with acopy of current nursing license.

3. Maintains required competencies

4. Completes assigned program tracks assignedby DON/CNO/Education Facilitator.

5. Completes appropriate level of ClinicalAdvancement within established timeframes

D. Membershipin appropriate professional organizations.

E. Assumesresponsibility for maintaining/enhancing physical health and alleviating stress

1. Attendance

F. Demonstratescompetency in a variety of nursing skills as demonstrated and evaluated on at lease an annual basis.

1. Attends annual skills fair

G. Displaysa “customer service” attitude toward patients, visitors, and other staff members at all times.

1. Demonstrates basic telephone skills (how toanswer, place on hold, and transfer a call.)

2. Utilizesintercom

3. Demonstrates how to page physicians orothers on call.

H. Abidesby all safety, infection control, and other guidelines as required.

1. Follows guidelines for caring for patientsin isolation

2. Utilizes hand-washing techniques

3. Cleans equipment between patient usage.

4. Reports personal symptoms of suspectedillness or contagious disease to the Employee Health Nurse.

5. Demonstrated knowledge of universal bloodand body fluid precautions

I. Promotesan ethic of continuous quality improvement in all matters

associatedwith the position, and documents specific quality improvement implementation.

J. Performsall other tasks and duties as may be assigned.

K. Providesa level of competency to treat patients 18 and older.

1. Adults:

a. Involves them with care planning by meetingany needs they

identify during assessment

b. Identifies their normal patterns of livingand strives to attain them

2. Geriatric:

a. Strives to obtain understanding by speakingdistinctly and

moving slowly.

b. Involves family as much as possible

IV. DRESSES AND PRESENTS SELFIN A PROFESSIONAL MANNER AT ALL TIMES. ADHERENCE TO THE DRESS CODE POLICY IS REQUIRED.

V. WEARS HOSPITALISSUED NAMETAG AT ALL TIMES WHILE ON DUTY

VI. CONDUCTS SELF ETHICALLYAT ALL TIMES.

VII. UPHOLDS ALL SERVICE STANDARDS

A. Safety- We do no harm and create an error-freeenvironment.

1. Follow environment of care plan

2. Follow established clinical practices

3. Routine assessment of the environment for high riskswith immediate correction (look for dangerous things and fix them; identifyhigh risk issues and fix them)

4. Pay attention to detail

B. Communication- We engage our customers in exchangingclear, timely and accurate information.

1. Listen carefully

2. Ensure understanding of treatment and services

3. Timely follow-up on commitments

4. Constantly learn about the customers and identifytheir needs

C. Courtesy- We treat everyone with respect, socialsensitivity and professionalism.

1. We acknowledge our customers with a smile and treatthem as welcomed guests

2. Listen to our customers

3. Look at each interaction as an opportunity topromote courtesy with our customers

4. We treat each other as we treat our guests

5. We strive to exceed our customers expectations

D. Presentation- We provide a positive customerexperience through the appearance of our environment and employees.

1. Maintain a clean and organized environment,including workspaces

2. Control hospital odors

3. All employees are compliant with the dress code

4. All employees communicate in a professional andcourteous manner, including body language

5. Protect the privacy of patients

6. Maintain a quiet atmosphere

E. Efficiency- We use resources appropriately tobenefit the customer and the organization.

1. Availability, assessment and application ofresources

2. Do it right the first time

3. Pay attention to details

4. Save steps through planning

5. Timely responses