Registered Nurse

Summary

Under the direct supervision of the Director of Clinical Services, demonstrates proficiency in administering the fundamentals of the nursing process, contributes to the nursing assessment and the development of the nursing care plan, and participates in the evaluation of nursing care. Shares responsibility for individual patients or an entire patient population.

Essential Duties & Responsibilities

• Obtains and documents nursing history from the patient and/or significant other that is comprehensive of present condition and prior problems.
• Performs basic assessment of the patient, indicating adequate knowledge of anatomy, physiology, and pathology.
• Records vital signs, notes changes, and pursues more-specific investigation as needed.
• Makes pertinent observation, using language that correctly describes body parts and functions, and draws logical conclusions which direct formation of nursing care plan.
• Identifies abnormal diagnostic data and shows a fundamental understanding of its implications by reporting information to the physician and others caring for the patient, and by incorporating information in the nursing care plan.
• Uses assessment information to develop a care plan before the end of duty time that communicates enough information for incoming personnel to adequately care for the patient.
• Reviews and develops care plans for assigned patients.
• Includes the patient and his or her family in planning care, establishing priorities, and setting goals.
• Uses care plans as a basis for providing safe and therapeutic care to patients.
• Communicates with the patient and his or her family and other members of the health care team in carrying out the goals of the care plan.
• Indicates an understanding of the roles of other health-care team members in patient care and incorporates their input into the care plan.
• Performs competently those technical skills considered basic to the type of care given in each setting.
• Identifies patient teaching needs and provides elementary instructions for the patient and his or her family.
• Notes discharge planning elements and incorporates these in care plans, demonstrating an awareness of community care available after discharge.
• Responds appropriately in urgent and/or emergency situations.
• Evaluates and notes the individual patient response to nursing care defined in the nursing care plan and medical records.
• Understands and uses Centers for Disease Control and Prevention (CDC) Standard Precautions, OSHA's Occupational Exposure to Bloodborne Pathogens standard, and follows established infection control, hazardous communication, and other safety rules.
• Participates in the evaluation of nursing care given to groups of patients.
• Identifies strengths and weaknesses of nursing care systems.
• Supports standards of nursing care through adherence to existing policies and procedures.
• Supervises care given by nonprofessional personnel, providing instruction as needed.
• Regularly attends unit conferences and makes recommendations for improvement in patient care via the patient care conference and unit conference.
• Actively participate in interdisciplinary team conferences
• Participate in QAPI Program
• Other duties as assigned

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

Graduate from an accredited school of nursing.

Language Skills

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from managers, patients, and the general public.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have knowledge of Electronic Medical Records software and Business communication software.

Certificates and Licenses

Current licensure as a Registered Nurse in the state in which practicing.

Supervisory Responsibilities

This job has no supervisory responsibilities.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Specific vision abilities required by this job include close vision and ability to adjust focus. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. Requires standing, walking, pushing, pulling, and lifting.