Assess physical, psychosocial, growth and development of the patient.

Nursing assessment is completed at the beginning of each shift and as patient's condition changes.

Admission assessment is completed on assigned patients within 12 hours of admission.

Physician is informed in a timely manner based on implications and severity of significant deviations from the norm of the patient’s condition.

Unit based and age appropriate guidelines are followed in performing patient assessment.

Plan of care is developed within 12hours based on nursing assessment, customized to include patient specific problems and needs.

Patient /family involvement in discharge planning and teaching needs are included in plan of care.

Patient rounds are conducted every two hours.

Physician orders processed by ward clerks are co-signed within 2 hours. Stat orders are processed within 15 min. and routine orders within 2 hours.

Medications are administered per hospital policy.

Patients are assigned to team members based on knowledge, skill level and patient acuity.

Plan of care is updated and revised following medical orders, and in accordance with nursing policy and procedures as patient condition and needs change and input updated from other team members.

Nurse manager and/or medical personnel are notified immediately of potential patient crisis situations.

Patient care assignments are revised based on unit census and activity, team members, availability, patient care needs and patient acuity.

Assessment, assignments, resolutions, planned goals and nursing care are documented per policy.

Crisis situations are documented before end of shift including patient condition preceding, during and after the crisis, as well as medication, treatments provided and outcome or status at end of shift.

Shift reports accurately reflect patient status and needs are communicated in order of priority at the beginning and ending of the shift and upon patient transfer.

Appropriate hospital department or external agency is consulted to justify patient’s immediate transport and discharge

Pertinent and timely information is provided to members of the nursing team and the multi-disciplinary patient care team.

A professional, helpful and friendly manner is used in interactions with hospital personnel and customers.