DIRECT PATIENT CARE:

Provides direct care to patients that are consistent with the philosophy and the goals of the Nursing Department – Patient Care Unit.

Initiates and follows through with planning for discharge or continuing care.

Performs assessments focusing on the physical, physiologic, and cognitive status of the patient.

Utilizes the nursing process in providing care to patients’ and families.

Demonstrates a sound knowledge base and decision making in the administration of nursing care for a designated patient population.

Complete patient care assignments in accordance with acceptable standards.

Attends to patient satisfaction needs in a courteous manner and timely fashion.

NURSING PROCESS/DOCUMENTATION:

Formulates problem-goal list plans/statements that include nursing measures that will facilitate the medical care prescribed and that will restore, maintain, and promote the patients’ well-being.

Determines the scope of the plan by anticipating the needs of the patient and updates it as needs change.

Document a plan of care that reflects current practice standards and patient education.

Document all aspects of care as it relates to the patients’ needs, problems, capabilities, and limitations as reflective of the plan of care and response to the care.

Identifies the learning needs of patients’/families and initiates/evaluates a tracking plan to meet these needs.

Document within the patients’ records instructions given to patients’/families and their understanding of these instructions.

QUALITY ASSURANCE:

Effective in maintaining and assuring the quality of services provided to all patients’, visitors, guests, and co-workers.

Participate in standards development and implementation.

Demonstrates knowledge of goals of the Quality Assurance Program and supports implementation.

Participates in the evaluation and monitoring of the quality of patient care.

Pursue opportunities to improve patient care and resolve identified problems.

Attends unit meetings and assists with the development of the plan of action to correct deficiencies.

PATIENT SAFETY:

Administers nursing care in accordance with safety regulations identified by the institution.

Practices in accordance with legal parameters related to the delivery of nursing care and unit functioning to provide a risk-free environment.

Provide for a safe and accurate administration in accordance with hospital policy and physicians’ orders of:

• Medication
• Intravenous fluids
• Blood and blood products

Maintains all required checklists.

PATIENT RIGHTS:

Demonstrates an awareness and knowledge of the patients’ rights and responsibilities while receiving care within the institution.

Demonstrates knowledge of the referral mechanism when a patient believes their rights have been violated.

Demonstrates knowledge of the hospitals’ policy governing the application of supportive devices and/or restraints to a patient.

EDUCATION/PROFESSIONAL DEVELOPMENT:

Complete the mandated education programs on an annual basis.

Attends continuing education programs for:

• Professional self-development and/or
• Certification in specialty

Demonstrates competency in psychomotor skills and new equipment. Participates in orientation/staff development.

JUDGMENT/PROBLEM SOLVING:

Identifies unit and/or patient care problems and participates in problem-solving approaches.

Collaborate with other disciplines and members of the health care team.

Demonstrates leadership and delegation of tasks and duties and direction and coordination of the health care team, patient care and unit activities.

COMMUNICATION:

Ensures that all patients, visitors and guest, as well as co-workers receive personalized, prompt attention and are treated with receptiveness, dignity and respect, no matter how limited the contact.

Reports any changes in patients’ condition to the appropriate individual(s) and documents these significant changes in the patients’ record, in a timely fashion

Retain Accountability for nursing care provided by:

• Orienteer
• Nursing students
• Licensed practical nurses
• Other support personnel

Act as liaison between the patient, physician, and other disciplines.

Notify appropriate department of movement of a patient within or out of the institution and logs activity in appropriate record.

Participates in staff meetings and committees a required.

Complies with hospital policy and unit dress code appropriate to practice settings and professionalism.

Performs other duties as assigned.