RN-Clinical - N7010

Job Summary The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care care activities during the patient‘s hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach. Job Responsibilities and Requirements POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA Essential Functions: The following are essential job accountabilities and performance criteria.

1. Per_h IMS comprehensive nursing assessment/reassessment. Criteria A) Performs age-appropriate admission assessment or transfer assessment. Obtains input from family/guardian when appropriate. B) Accurately and completely documents findings. C) Per_for ms assessment of post-op/post-invasive procedure patients. D) Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization. E) Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc.
2. Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant. Criteria A) Identifies short and long term goals based on patient care needs. B) Formulates nursing interventions to achieve desired patient outcome. C) Involves disease specific evidenced based practice into nursing care plan and other documentation.
3. Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status. Criteria A) Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients. B) Provides, coordinates and communicates patient care, including accurate Handoff Communication Reports. C) Administers and documents medications accurately according to policies and procedures. D) Monitors, maintains and documents accurate IV fluids and parenteral nutrition according to policies and procedures. E) Completes referrals as indicated by assessment data. F) Requests consultation for special needs, equipment, or information for patient and/or family. G) Provides patient/family education and discharge planning per documentation guidelines and protocol. H) Clarifies all physician orders as warranted. I) Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record. J) Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate. K) Documents ‘Readback‘ for all telephone/verbal orders. L) Takes telephone/verbal orders only in emergency situations. M) Recognizes changes in patient‘s condition and takes appropriate nursing actions. N) Involves the family/guardian when providing care and in decision-making as appropriate. O) Recognizes risks for patient and takes appropriate action. P) Incorporates use of Infection Control practices in daily care.