Registered Nurse

SUMMARY   

The Cleft Palate Program RN works collaboratively as an active member of the interprofessional team to provide therapeutic patient and family centered care. Systematically and continuously collects and assesses data related to patient health status to develop, execute and evaluate the plan of care; utilizes evidence to drive clinical decisions and practice related to individual and population health. Establishes goals and strategies for meeting care coordination needs across settings with the patient, family, and/or other care providers. The Cleft Palate Program RN considers factors related to safety, effectiveness and fiscal accountability in planning and delivering care. Delegates and supervises care in accordance with the Nurse Practice Act. Participates in continuous quality improvement initiatives and assumes responsibility for their professional development.

DUTIES AND RESPONSIBILITIES

• Executes nursing interventions by collaborating with the interprofessional team. incorporating appropriate standards of care and practice and patient outcomes. 
• Assesses and systemically collects any data related to patient health status and works in collaboration with the care team to develop the plan of care. 
• Evaluates patient’s response to plan of care and works in collaboration with the interprofessional team to make any needed adjustments. 
• Utilizes data to continuously meet care coordination needs across settings in conjunction with the patient, family and/or other care providers. 
• Assumes responsibility and accountability for effectively managing nursing care of individual patients. 
• Documents nursing assessment and interventions to reflect comprehensive and integrated approach to patient care. 
• Provides care that is safe, ethical, patient and family-centered, culturally congruent and evidence-based. 
• Documenting patient care in an electronic medical record. 
• Familiarization of cardiac rhythms and telemetry. 
• Infection control standards. 
• Excellent verbal, written, and presentation skills. 
• Make knowledgeable clinical assessments and judgments. 
• Educate staff. 
• To provide counseling and emotional support with compassion and respect for the individual. 
•  Prioritize tasks as needed for patient care. 
• Provide support to the members of the care team. 
• Must possess initiative and ability to work independently. 
• Ability to maintain confidentiality of medical records.
• Other duties may be assigned. 

PERFORMANCE STANDARDS AND SUCCESS INDICATORS

• Excellent interpersonal skills.
• Positive Physician and staff relations as evidenced by positive comments and confidence level.
• To provide high quality health care to community members and patients. We are committed to compassionate, personalized, comprehensive and responsive treatment of all of our patients.
• Follow-up on ordered tests, procedures, surgeries, and failed appointments are timely as evidenced by employee log and chart documentation.
• Maintains a neat and orderly work environment, demonstrates the ability to organize and prioritize work during heavy workload situations to expedite patient care.

• Demonstrates continued competence in treating, and caring for individuals based upon age-specific needs utilizing a developmental perspective under the direction of the Nurse Practitioner, Physician, or Registered Nurse:                   

1. Maintains own clinical expertise and facility clinical practice.
2. Displays an understanding of each patient’s cognitive, physical, emotional, and chronological maturity in the treatment, and care undertaken based on age-specific criteria. 
3. Appropriately modifies approach to the patient based upon patient age utilizing a developmental perspective.
4. Provides appropriate age-specific interventions related to safety issues.

• Demonstrates appropriate knowledge and competence of designated skills identified for position in Cleft Palate Program:       

1. Checks updated schedule each morning and prepare supplies and equipment. 
2. Completes review of medical record.
3. Promotes physical comfort and provide emotional support and safety for patient.
4. Administers and charts medications as ordered by Nurse Practitioner, Physician Assistant, or Physician. 
5. Reinforces and clarifies Nurse Practitioner or Physician instructions and explanation of procedures to patient. 
6. Provides nursing care and appropriate monitoring according to policies and procedures. 
7. Communicates relevant information to Nurse Practitioner, Physician, Facility Manager and appropriate staff. 
8. Provides for patient safety by use of monitors, side rails, and assistance in ambulating and instruction on the use of call bell in bathroom. 
9. Provides instructions according to patient need.
10. Completes nursing documentation. 
11. Provides emergency care according to physician and administrative policy. 
12. Sets priorities to facilitate the flow of patient efficiently.
13. Cleans equipment according to procedure. 
14. Assists with patient calls. 
15. Reviews charts for completeness and signatures of physicians. 
16. Assists with cleaning of clinical areas according to policies and procedures. 
17. Prepares and restocks area for following day. 
18. Checks inventory and notifies appropriate staff member to order.
19. Initiates appropriate infection control measures. 
20.  Maintains an environment that promotes safety:

1. Electrical safety measures
2. Oxygen, Suction, and all other Resuscitation Equipment
3. Noise Control/Traffic Control

QUALIFICATIONS

• Current California RN License.
• Minimum of 2 years experience in pediatrics. Willing to train new grad.
• Current BLS, ACLS, and PALS certification.
• Conversational Spanish required. 

ADDITIONAL REQUIREMENTS:

Ability to work variable shift schedules and rotate coverages as need in Cleft Palate Program Clinic.  Variable shift schedules including morning, evening, weekend and holidays.   

Complexity:

Ability to take vital signs, maintain quality control standards. Must be able to multi-task efficiently and effectively and take the direction of multiple sources, while maintaining an effective working relationships with patients, medical staff and the public. Ability to perform highly detailed work with sustained attention and ware while providing/obtaining information on numerous inquiries is paramount to success in this position.

PHYSICAL REQUIREMENTS:

Ability to withstand long periods (66-100% of the time) of walking, standing, bending, sitting, holding limbs and or equipment for long periods of time. Spending extended periods of time verbally communicating with patients, families, healthcare team members, and visitors. Requires a high level of dexterity for safe handling of patients, equipment, and supplies weighing up to 50 pounds.

WORK ENVIRONMENT:

Strenuous work environment with the ability to make decisions. The Cleft Palate Program is a fast paced facility with long hours of operations that include weekends and holidays. Team work with other technicians and staff, is highly demanded.     

MENTAL DEMANDS:

Must demonstrate an ability to prioritize job responsibilities. Multi-tasking, able to demonstrate fast learning ability for clinical needs.  Effectively cope with typical job stress. Must be able to act calmly and effectively in a busy or stressful situation.