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• Completes or reviews the admission assessment of the patient and utilizes it in the nursing process.
• Performs focused physical evaluation of the patient at the beginning and end of each shift, on patient transfer and/or upon discharge.
• Documents and reports abnormal physical findings to the physician and/or other appropriate personnel.
• Gives/receives reports on patients.
• Summarizes patient data and identifies appropriate nursing diagnosis/interventions and patient needs during shift, transfer and/or interim reporting.

• Develops nursing plan of care, interventions and outcomes. Revises and updates the nursing care plan as necessary.
• Sets/revises priorities for direct patient care activities by acuity/urgency of need.
• Determines and communicates nursing orders.
• Delegates tasks to others, making appropriate assignments.
• Oversees nursing care of all assigned patients and assures documentation is completed.
• Incorporates patient education into care plan as appropriate. Provides patient education or contributes information for discharge planning.

• Administers medications according to hospital policy and procedure, documenting route, dose and time.
• Provides direct patient care including therapeutic treatments and diagnostic procedures according to patient and family needs.
• Implements physician’s orders according to hospital protocols and procedures.
• Reports/receives assignments to ensure continuity of care.
• Demonstrates clinical skills, performance of procedures, treatments and patient care.
• Directs patient education and documents outcomes, leads and coordinates education for the patient care partner.
• Leads and coordinates patient care activities in designated unit-based geographical assignment.
• Uses clinical judgment and integrates data for expected patient outcomes.
• Monitors care given and assures documentation is complete.
• Oversees patients discharge/transfer process and completes relevant information.

• Documents patient responses to clinical interventions.
• Reviews and updates the patient’s plan of care. Communicates significant changes in patient status to others as appropriate.

• Promotes patient satisfaction, anticipates and responds to needs of others; provides assessment in a courteous manner; treats others with care and respect, maintaining privacy, confidentiality and dignity.
• Serves as patient/family advocate facilitating patient’s ability to make informed decisions about their care.
• Participates in nursing or hospital performance improvement activities for monitoring and evaluating important aspects of care; nursing practices standards, and/or outcomes of care.
• Demonstrates professional behavior and interpersonal skills to reflect MCRMC mission, vision, and values.
• Participates in nursing research projects as requested.
• Complies with State Board of Nursing educational requirements. Participates in organizational and departmental mandatory educational offerings, completing all requirements.
• Promotes own professional development through participation in education, unit-based meetings and committees.
• Complies with nursing and administrative policy and procedure manuals.

• Complies with hospital and departmental safety policies.
• Documents actions and/or specifies the measures taken to ensure patient safety.
• Complies with infection control and universal precaution guidelines.