General Summary

• Independently provides and coordinates individualized patient care consistent with the mission and values of the University of Maryland Rehabilitation and Orthopaedic Institute (UMROI)and in accordance with professional and regulatory standards.
• Accountable to patients and families for processes and outcomes during an episode of care. Serves as a fully engaged member of the interdisciplinary patient care services team. Participates in cost effective strategies that optimize patient outcomes.
• Must demonstrate the knowledge and skills necessary to provide care appropriate to the age, culture, ethnicity, and specific individual diagnostic needs of the patients served in his/her department. He/she must be able to assess and interpret data about the patient’s status in order to identify each patient’s specific needs and provide the care needed by the patient group (pediatric, adolescents and/or geriatric patient group, culture and diagnostic specific).
• Consistently expresses and demonstrates compassion and courtesy for patients. Extends courtesy and support to patient's families/visitors.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Electronic/Paper documentation- Accurately and concisely records patient care along the continuum. Attends required training on electronic documentation. Demonstrates ability to document/enter data correctly in the medical record/EMR verified by chart review.
• Wound Care- Manages patient care to promote healing and maintain structural integrity of the skin. Performs comprehensive skin assessment and wound care for the patient as required. Identifies risk factors for impaired skin integrity and/or wound impairment. Implements appropriate strategies and/or treatment measures to prevent skin deterioration. Identifies criteria for nutrition and wound care consultative services.
• Pain Management-Intervenes, alleviates or reduces pain to a level of comfort acceptable to the patient. Assesses the patient for pain on initial admission/visit and during on-going care activities as evidenced by chart audit. Incorporates appropriate interventions to manage pain. Review of documentation. Completes annual competency for pain recognition and pain therapies skill checklist on file.
• Blood Glucose Monitoring (Accu-check) - Able to accurately perform testing and manage the care of the patient based on results achieved and clinical findings. Attends annual training for review and updates on blood glucose testing and monitoring equipment. Demonstrates proper technique and skills needed for obtaining accurate blood glucose results and documenting findings. Completes annual didactic and/or written testing with results kept on file. Quality monitoring performance is assessed annually and/or as needed at intervals based on performance criteria.
• Collection of Specimens - Accurately follows procedural guidelines and uses proper technique(s) to obtain bodily specimen collection for laboratory testing. Completes annual didactic and/or written testing with results kept on file. Incorporates proper techniques for patient identification, method for collection of appropriate specimen(s), and documentation.
• Management of Malignant Hyperthermia- Demonstrates accurate use of assessment skills for patient exhibiting signs and symptoms of Malignant Hyperthermia (MH). Demonstrates measures to maintain thermoregulation to prevent complications Able to safely care for patient with MH and follow recommended practices for care based on evidence-based guidelines, MD orders, and overall condition of the patient. Able to demonstrate or verbalize proper use of MH cart. Successfully completes Healthstream module, which includes a video, post-test, and competency marathon annually.
• Fire in the OR - Able to accurately assess and monitor environment for potential hazards resulting in a flammable event. Maintains safety of the Operating Room and surrounding area during daily practice. Follows policy and procedure as well as all regulatory requirements for Fire safety. Attends inservices, watches video, successfully completes written testing, responds appropriately to Fire drill, and/or participates in competency marathon on an annual basis.
• Documentation and care of implants - Maintains safe practices and safe environment involving the care of implants. Follows recommended procedures and precautions for patients receiving or who possess an implant during any surgical procedure. This includes pacemakers and defibrillators. Maintain current knowledge and/or update skills by attending inservices, seminars, successfully passing written testing, computer-based education, and/or competency marathon for the care of implants on a yearly basis.
• Equipment set-up - Demonstrates ability and clinical knowledge for set-up and operation of Andrews table, Jackson table, Steris equipment, Smith and Nephew Fracture table, Stryker tower, Positioning devices, Endoscopic devices, and Steam sterilizer. Peer review and/or skills checklist will validate this skill.
• Creates and maintains an aseptic surgical environment - Monitors and maintains room set-up as per policy and procedure. Follows practices for maintaining aseptic surgical environment per guidelines. Remains responsible for care of the environment for any Skills checklist and/or Peer review will be used for validation.
• Surgical responsibility - Surgical duties include accurate documentation for any / all counts, universal protocol, and monitoring of patients during all procedures and surgeries. Able to perform all clinical duties required for surgical roles. Peer review, documentation, and feedback from other team members will be used to validate this skill.
• Continuous Quality Management - Actively participates in efforts to maintain and/or achieve quality care status. Assists with the development or participates in initiatives for quality improvement based on regulatory requirements and Kernan goals. Peer review and documentation review will be used to validate this skill. Involvement in inservices, seminars, and committee work will also be considered.

Respect for individuals, Customer Service, Teamwork and Collaboration:

• Models excellence in customer service behaviors. Identifies and acts on opportunities to respond to customer requirements. Takes action to prevent potential customer complaints.
• Initiates service recovery processes and completes appropriate documentation in response to customer concerns.
• Demonstrates the knowledge and skills necessary to provide care appropriate to the age, culture, ethnicity, spirituality, and individual diagnostic needs of the persons served.
• Uses hand-off communication to convey appropriate patient/clinical information.
•  Identifies and addresses potential breeches in patient information management and confidentiality (HIPAA) issues.
• Serves as a collaborative resource and patient advocate within the interdisciplinary team.
•  Precepts, mentors and provides an inclusive environment for peers, orientees and students.
• Provides performance feedback as requested within peer review systems.
• Invoices difference in opinion professionally through appropriate channels.

Leadership, Clinical and/or Technical Skills:

• Exhibits a high level of critical thinking and clinical competency related to the patient population in the area of assignment.
•  Assesses, plans, implements and evaluates the treatment and progress within patient care delivery process.
•  Demonstrates effective documentation practices including required components of assessment, care planning, treatment and patient progress.
• Acts as a change agent within the area of assignment by supporting unit/organizational goals and participating in problem solving initiatives.
• Shares in charge responsibilities ensuring balanced assignments based on skill mix and changing patient care requirements.
• Monitors competency and performance of fellow staff.
• Provides a coordinated approach to patient/family education in accordance with patient needs and barriers encountered.
• Other duties, as assigned.

We’re making Maryland stronger!
With roots that go as far back as 1895, the UM Rehab & Ortho Institute continues to be a pioneer in orthopedics and neurological disorders. From bones to brains, our cutting-edge hospital heals even the most serious of injuries, specializing in everything from total joint replacement to spinal cord injuries and neurological condition. In total, our 141-bed facility welcomes over 3,000 patients every year. As the state’s largest provider of inpatient rehabilitation services, we offer some of the most advanced therapies for stroke, spinal cord injury, traumatic brain injury, orthopedic and sports injury, among many others.

Education & Experience

• Licensure as a Registered Nurse in the State of Maryland is required.
• Current CPR card required.
• Certification in area of specialty preferred.
• Graduate of an approved RN program.
• BSN, or enrollment in a BSN program, is highly desirable.
• At least one year of nursing experience that includes recent applicable clinical experience in a comparable setting.

Knowledge, Skills and Abilities

• Demonstrated/documented highly effective interpersonal, verbal and written communication skills.
• Demonstrated effectiveness as an interdisciplinary team member.
• Ability to learn and apply computer systems in order to manage patient information.
• Highly effective verbal communication skills including courtesy, resourcefulness and efficiency in answering questions, giving directions, locating staff and explaining hospital/departmental policies and procedures are necessary. Verbal communication skills may include communicating with an interdisciplinary team, patients, and families. Effective writing skills are also required in order to take messages and maintain miscellaneous records, receipts, reports and logs.
• Systems Assessment/Reassessment
• Medical Emergency Preparedness: Current CPR
• Medication Administration
• Fall Risk Assessment/Fall Risk Strategies
• Restraint application, monitoring and documentation
•  Infection Control: Standard Precautions, Isolation Precautions
• Braden Scale/Skin Care
• Charge Responsibilities
•  IV Catheterization and Care
• Bladder Scan, Catheterization and Care
• Respiratory Care: suctioning and trach care, etc.
• Oxygen Therapy
• Orthopaedic/Rehab Device Care; e.g. braces, splints, CPM.
• Orthopaedic/Rehab Device Care: CPM

Quality and Patient Safety:

• Ensures the safety of the clinical environment for patients, visitors, and other staff members.
• Demonstrates knowledge, practice, and accountability for compliance with the TJC National Patient Safety Goals.
• Detects, reports, and takes action to avoid or correct safety risks.
•  Reports adverse events and near misses to appropriate management authority.
• Initiates fall risk assessment and implements fall prevention strategies.
• Incorporates safe lifting techniques and body mechanics in daily practice

Cost Effectiveness:

•  Proactively seeks opportunities to improve patient flow, reduce length of stay, and prevent care delays.
• Employs practices that improve efficiency, reduce costs, and maximize charge capture when delivering patient care.
• Effectively sets priorities and demonstrates time management skills.
•  Inputs efficient and balanced self-scheduling data in compliance with staffing targets and guidelines.
• Assists in identifying new technologies that reduce the cost of care or improve patient outcomes.

Education and Research:

• Assumes responsibility for maintaining competency and clinical knowledge base related to role.
• Identifies and addresses learning needs of self and fellow staff.
•  Completes written and/or computerized training.
• Attends required in-services and mandatory staff meetings.
•  Supports or participates in approved research projects.