General Summary

• Under limited supervision, the Registered Nurse is responsible for the assessment of patients including the development, evaluation and modification of the plan of care. The RN interprets and performs complex patient-care procedures specific to their area of expertise. RN’s are members of the Care Team and Support Team and have accountability to function as a team to accomplish patient outcomes identified in the pathway/plan of care.
• The Registered Nurse is a professional care giver who assumes responsibility and accountability for care given to a group of patients for a designated time frame. The RN provides care to those patients via therapeutic use of self, the nursing process, the environment/technology, and other healthcare team member, according to established standards. Patients served include all age groups (Infant through Older Adult as identified in Performance Standards).

Principal Responsibilities and Tasks

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

• Participates as a member of the Patient Care Team by providing functional supervision and by delegating duties to other care team members as they provide appropriate direct patient care duties.
• Carries out performance standards for charge nurse; when assigned that duty, as delineated in the delivery of care methodology.
•  Assigns nursing care responsibilities to staff.
• Participates as a member of the care team to provide direct care requiring the skills/qualifications of the RN.
• Performs assessment/data collection in an ongoing and systematic manner, focusing on physiologic, psychological and cognitive status.
• Formulates a goal-directed plan of care with patient/family which is prioritized and based on determined nursing diagnoses/patient care needs/problems and patient outcomes.
• Functions to establish priorities of patient care based on essential patient needs and available unit resources of time, personnel, equipment and supplies.
•  Identifies patient/family learning needs and implements appropriate measures to meet these.
• Performs documentation duties on unit and in patient record which are timely, accurate, concise and legible.
•  Demonstrates competency in selected psychomotor skills as outlined in generic and unit specific manuals and performance standards; assists physicians with procedures; implements care in a knowledgeable, skillful, consistent and continuous manner.
•  Demonstrates appropriate delegation of tasks and duties in the direction and coordination of healthcare members, patient care and unit activities.
•  Demonstrates awareness and sensitivity to patient/family rights, as identified with the institution.
•  Demonstrates competence in patient/SO education, as validated by direct clinical observation.
•  Identifies and responds to patients’ need for pain management from arrival to departure.
• Evaluates effectiveness of care given by all healthcare team members in progressing patient toward outcomes.
• Collaborates with Case Manager to evaluate outcomes and effectiveness of plan of care.

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Education and Experience

• Graduation from an accredited nursing education program approved by the Board of Nursing or found by the Board to be substantially equivalent to the programs in Maryland.
• Currently licensed as an RN in the state of Maryland. Successful completion of a refresher course within past 6 months if nursing practice has not occurred within the past 5 years.
• Current BLS certification or obtained prior to providing direct patient care is required.

Knowledge, Skills and Abilities

• Ability to demonstrate knowledge and skills necessary to provide care appropriate to the patient population(s) served. Ability to demonstrate knowledge of the principles of growth and development over the life span and possesses the ability to assess data reflective of the patient's requirements relative to his or her population-specific and age specific needs.
• Highly effective verbal and written communication skills are required to interact with patient families, departmental units, medical and nursing staff on all essential matters. Demonstrated/documented effective interpersonal skills.
• Maintains updated hospital safety and other mandatory training.
• Updated immunizations as recommended per practice area.

 Patient Safety

Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.

• Takes action to correct observed risks to patient safety.
•  Reports adverse events and near misses to appropriate management authority.
• Implements policies, procedure, and standards consistently in the performance of assigned duties.
• Develops effective working relationships and maintains good communication with other team members.
• Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.

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