RN Med/Surg -Charge Nurse Role

RN Med/Surg - Charge Nurse Role

Harrisonville, MO 64701

Overview

Position Type: Full Time Job Shift: Night Education Level: 2 Year Degree

Description

Department Name: Med Surg

Title: Charge RN

EEOC Classification: Non-Exempt

Primary Purpose: To provide quality patient care following the standards using the nursing process in order to maintain a safe environment. To provide patient and family education and to provide proper documentation for billing. Performs other duties as assigned.

Formal Policy-Setting Responsibilities: No formal responsibility. The policies associated with the job's purpose and essential responsibilities are set by others.

Routine Decision Making: Alterations in patient assessment; determines patient educational requirements; determines when to contact the physician.

Formal Supervisory Responsibility: Some formal supervisory responsibility.

Required Knowledge: Nursing process; critical care; medications and treatments; growth and development; disease processes; interpretation of lab results.

Required Skills and Ability: Ability to meet deadlines, decision making and thorough communication skills; assessment skills; time management skills; proficient computer skills; clinic skills; problem solving skills; and knowledge of hospital policies and procedures.

Unusual Working Conditions: Risk of blood, body fluid contamination. Risk of injury related to poor body mechanics. Risk for injury from aggressive, combative or disoriented patients. Potential exposure to hazardous drugs and chemicals.

Education and Certification: RN degree required, BSN preferred, current RN licensure in the state of Missouri or compact licensure to practice in Missouri required; BLS, ACLS, PALS and NIH Stroke Certification required within 90 days of being hired. Annual stroke education hours per hospital policy. NVCI or equivalent class as determined to be required by the facility.

Age Specific Competencies: May provide care for infant (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs.); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

Qualifications

Essential Responsibilities and Tasks

A. Performs the assessment phase of the nursing process. (20% of time)

1. Ensure all patients are placed on the Med Surg Unit within thirty minutes of being notified of the admission/transfer if bed is available.

2. If needed, completes a patient admission assessment that includes a pertinent patient history, assessment of body systems, medication history and other screenings within four (4) hours of arrival to the medical surgical unit.

3. Assesses data relative to age specific needs for every patient within four (4) hours of patient's arrival to the unit if needed.

4. Assesses patient/family learning needs within four (4) hours of arrival to the unit if needed.

5. Completes appropriate pain assessment of each admission, during each shift and as needed.

B. Performs the planning phase of the nursing process. (15% of time)

1. Completes an individualized care plan based on patient diagnosis and assessment with each admission, during each shift and as needed. Approves care plan for new patients assigned to LPN's.

2. Collaborates with interdisciplinary team to facilitate the plan of care after reviewing the providers admission orders and for any functional and health screenings that are required.

3. Interprets significance of abnormal patient findings after assessing patient on admission, during each shift and as needed.

4. Utilizing the 'AIDET' (Acknowledge, Introduction, Duration, Explain, Thank) model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals.

5. Updates white boards each shift, to include personalized patient goals and pain control.

6. Bedside report to occur every shift between oncoming and off-going staff.

C. Performs the implementation phase of the nursing process. (20% of time)

1. Implements patient care throughout each shift.

2. Documents and reports significant abnormal patient findings to the provider immediately.

3. Is knowledgeable of location, care and operation of Medical Surgical equipment.

4. Acts rapidly, effectively and manages self and others during emergency situations.

5. Administers IV's and medications as ordered within one hour of time scheduled according to the five (5) rights on every patient.

6. Ensures all provider orders are correctly recorded on EMAR, and in computer when acknowledging each order.

7. Ensures fall protocol is followed on each patient.

8. Accurately and correctly wastes used portions of controlled substances within a timely manner.

9. Performs narcotic count according to hospital policy.

10. Attaches patient's name band, fall risk, allergy band, etc. immediately after patient's arrival and upon bands being removed.

11. Responsible for making patient assignments for staff each shift.

12. Facilitates interdepartmental communication regarding patient care.

13. Assists with discharge process for all patients.

14. Address patient/provider concerns and escalate to manager if needed.

15. Round on patients as needed.

D. Provides patient and family education. (5% of time)

1. Provides patient and/or family's education based on assessments and re-assessments each shift and as needed.

2. Uses terminology appropriate to patient/family's knowledge base and age specific needs with each interaction.

3. Re-assesses patient and family's learning needs and abilities each shift and as needed.

4. Documents education provided including subject taught, method of teaching, who was taught, comprehension of information each shift and as needed.

5. Provides and documents patient and family follow-up instructions at discharge.

E. Demonstrates accountability to the nursing process through documentation. (15% of time)

1. Documents clearly the implementation of specific intervention, including details of methods used, with the time implementation and evaluation of patient response.

2. Utilizes only approved abbreviations in patient documentation each shift and as needed.

3. Documentation follows hospital and departmental policies for frequency and content.

F. Maintains a safe and comfortable unit. (15% of time)

1. Checks code blue carts each shift and upon using the cart ensuring it has an intact tag attached.

2. Ensures alarms on any assigned areas are audible to alert staff, each shift.

3. Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem.

4. Completes a requisition for repair and sends electronic work request before the end of the shift, pass on any issues to the next shift for follow up and provides a copy to the manager before the end of shift.

5. Assigns/completes, upon assignment, the job duty list for the unit each shift.

6. Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification.

7. Utilizes correct method of barcode scanning patient identification bracelets for medication administration via EMAR 97% of the time.

8. Utilizes correct method of barcode scanning patient medications for medication administration via EMAR 95% of the time.

9. Completes patient assignment record each shift.

10. Assesses the number and level of personnel needed based on the staffing plan each shift.

11. Provides thorough handoff communication to the next shift.

G. Develops and promotes unit/hospital initiatives. (10% of time)

1. Plans, develops and evaluates self-objectives, annually.

2. Participates in planning ways to solve problems and make improvements in the Medical Surgical unit quarterly, and as needed.

3. Participates in implementing planned changes and activities to improve the Medical Surgical unit quarterly, and as needed.

4. Evaluates planned changes and activities to improve the Medical Surgical unit, quarterly, and as needed.

5. Attends unit staff meetings 5= 100%, 4= 81% - 99%, 3= 75% - 80%, 2= 5