SMRMC Full Time Surgical Service Single ASC

Job Description

Under general supervision of the Chief Nursing Officer, Associate Chief Nursing Officer, Nurse Manager and direct supervision RN-1, the Charge Nurse uses the nursing and management process to safely supervise the shift-to-shift performance of patient care and education, data/charge entry, accurate completion of physician orders, and customer complaint follow up. Collaborates with Nurse Manager, physicians, peers, nursing staff, and administration. At all times, charge nurse assignments will be determined by nursing management directives. The Charge Nurse uses the clinical nursing process to safely coordinate total patient care and education for an assigned number of patients. The Charge Nurse uses the clinical nursing process to safely administer medications, monitor patients and operate essential equipment used in treating and diagnosing patient's conditions. At all times, patient assignments will be determined by adjustment of department patient census and current staffing levels for the overall patient care which are reviewed shift-to-shift. The Charge Nurse will be assigned up to 40 hours per week according to the needs of the unit and staff. The Charge Nurse is expected to function within the scope of approved policies, procedures, and regulations for the department and organization. Will be responsible to assist with orientation, preceptorship, and management of personnel assigned to unit. Must be able to work and relate in a professional, non-defensive manner with peers, providers, mid-level providers, administration, patients, and visitors. Will be responsible to document total care given, review and maintain patient medical record per policy, and assist with accurate and timely entry of patient data, orders, and charges into computer system. Charge Nurse demonstrates responsibility for the assessing, monitoring and management of patients, administering medication and treatments as prescribed. Maintains clinical competence, continually learning to perform any job duty within the scope of RN practice. Demonstrates knowledge of and administers all medications safely and according to provider's order and hospital policy adhering to the 6 rights of medication administration: (i.e. Right Patient, Right Drug, Right Dose, Right Time, Right Route, Right Documentation), Demonstrates knowledge of high risk and critical medications. Documents adverse drug reactions and reports per departmental and pharmacy policy. Performs IV therapy while demonstrating skill and accuracy per provider's order and hospital policy. Monitors and documents the patient's level of consciousness. Promotes unit and organizational philosophy and goals. Assists with establishment of departmental policies and procedures that reflect the services provided by the department. Participates in organizational committees as assigned. Provides important information on trends related to patient outcomes to Manager. Demonstrates professionalism and reinforces professional behavior of staff members. Maintains current knowledge of regulatory requirements: IFC, CDC, DNV, MSDH, MSBN, Baby Friendly, Quality initiatives and CMS. Demonstrates knowledge and skill related to patient throughput and customer service / satisfaction providing kind, compassionate care to all patient types. Nurses are required to float between departments. The successful candidate will have to pass a pharmacology test for this position. Complete the yearly mandatory in-service (YMI) requirements is nonnegotiable and will be the responsibility of the employee to arrange, attend sessions and maintain current on HealthStream assignments.

DUTIES and RESPONSIBILITIES: The Charge Nurse (RN) is expected to function within the scope of approved policies, procedures, and regulations for the department, organization and MSBN. Develops and maintains contact with related health care professionals, peers, medical staff, and state associations to obtain information and support. Attends scheduled meetings; sends professional correspondence as a follow-up to meetings, seminars and off-site programs. Assimilates assessment information to formulate plan of care, initiate and continually updates plan of care based on acute, chronic, urgent, emergent illness and high-risk medications. Communicates patient needs to other disciplines and promotes discharge planning. Assessing, monitoring and management of patients: presenting clinical, chronic, urgent or emergent situation providing a standard of care. May be responsible to assist with orientation, preceptorship, and management of personnel assigned to unit. Must be able to work and relate in a professional, non-defensive manner with peers, providers, administration, patients, and visitors. Ability to cope with frequent unpleasant sights/smells and difficult patient/family behaviors, care for all patient types (i.e. COVID etc.). Demonstrate and deliver patient centered care. Patient Advocate providing KIND, COMPASSIONATE Patient Centered Care

Competency: Performs Surgical Service Skills R/T Med/Surg: Performs Directed Patient Care Familiar with P/P related to operation of unit equipment. Utilizes physician preference cards in planning and implementing care. Demonstrates ability to evolve form Laparoscopy to Laparotomy quickly and proficiently. Demonstrates ability to count sharps, sponges and instruments per P/P. Demonstrates ability to care for patient with any medical/surgical interventions and/or equipment. Demonstrates through knowledge of skills for all areas of department including pre-operative, intra-operative, recovery, and secondary recovery. Assists Anesthesia with induction, emergent & attaching proper monitoring devices as necessary. Maintains solid knowledge base of medications used

Demonstrates proper usage and protocols for electrocautery and cautery device. Has knowledge of all procedures, equipment. Monitors all patients carefully by using observation skills and monitoring of appropriate vital signs. Maintains patient care standards as set forth by SGNA, ASPAN, DNV, CMS, AORN, AMMI, OSHA, CLIA, AABB and CMS.

Demonstrates ability to perform surgical skin preparations. Demonstrates Knowledge of Blood Administration per policy and procedure: Correct patient, correct blood type and blood not expired, Appropriate time to administer blood after receiving from blood bank, Knowledge of proper time to return blood to blood bank, Knowledge of blood reaction signs and symptoms, Knowledge of blood band removal and replacement, Two people required to check blood prior to administering. Demonstrates ability to assist with bowel and cleansing preps. Communicates with patient in positive manner that meets the age-specific needs of the patient.


Competency: Possesses Knowledge and Skill R/T Surgical Care:

Assesses the health status of patients in a systematic and continuous manner. Documents health status data on patient care record/ EMR. Identifies nursing problems based on health status assessment, and documents these on the nursing plan of care. Able to recognize /identify/document Arrhythmia's and notify appropriate staff, Charge Nurse/ Nurse Manager/Director and intervene appropriately. Maintains solid knowledge base concerning Anesthesia and reversal meds and follows Anesthesia guidelines for lab studies. Assess Post-Op Tonsillectomy, D&C, gastroenterology, hernia, appendectomies, Ophthalmic, orthopedic, general, urology and all other IP/outpatient surgical patients for bleeding and other complications, intervenes appropriately and notifies Charge Nurse/Nurse Manager. Promptly report to the physician any abnormal findings which may complicate the procedure or reduce the probability of achieving the desired outcome given the current state of knowledge and knows lab values and clinical significance: a. CK- ISO's, b. ABG's. Demonstrates skills to manage emergency and on call procedures effectively. Communicates all pertinent patient information to physicians, offices, ancillary departments and hospital units effectively. Possesses knowledge of complications and emergencies, takes necessary action and competent in the use of the Defibrillator, Code/Crash Cart, Malignant Hyperthermia and CPR. Demonstrates competence in performing basic Post Anesthesia Recovery nursing procedures - vital signs every 15 minutes or more often, temperature, proper positioning, constant observation of patient and any other basic nursing procedures required. Possesses knowledge and skill on providing discharge instructions and necessary patient teaching to all outpatients and their significant others, in timely manner. Familiar with P/P related to transfer of patient to nursing unit. Collects all data required for Pre-OP assessment and teaching per hospital policy and procedure. Demonstrates knowledge of placing orders for labs, charging supplies, printing preference cards, using timecard correctly.


Performs time outs, surgical counts, sets up surgery suites, opening sterile supplies checking out of dates ensuring all instruments needed for case is in surgical suites providing basic care. Informed Consents- accurately handles informed consents according to policy and procedure. No blanks, no abbreviations, Patient/family understand surgical treatment plans and alternative treatments. Assistant listed if applicable with assistant's task listed, Appropriate witnesses according to policy, Left or right written when applicable, surgical site marked according to policy and procedure. Actively participate in Time Outs (everyone STOPS). Speaks up and Stops at any time you do not agree. Assists with patient education specific to post-operative care. Recognizes and reports high risk social situations. Adheres to visitation guidelines. Addresses patient's grief and loss needs of specific patients. Code Pink Competency, Malignant Hyperthermia Competency, Suicide Competency, Surgical Count Competency and Surgical Fire Competency.


Competency: Possesses surgical knowledge Base and Job Skill: Familiar with P/P related to operation of unit equipment.

Demonstrates ability to locate and utilize emergency supplies and drugs; Emergency cart supplies, Defibrillator, Malignant Hyperthermia * Cart in ASC recovery and in Cath Lab, Surgical Fire. Demonstrates skill in proper positioning techniques, Assessment, Body alignment and positioning, Equipment. Assures all areas are set up properly for safe, efficient operation. Understands and uses multiple accessory equipment properly. Show ability to clean and properly care for all equipment to maintain quality and prolong usefulness. Uses knowledge of infection control, disinfection, and sterilization for patients, staff, and department protection.

Understand and reports any equipment problems or shortages to Charge Nurse/ Nurse Manager. Restocks OR suite daily - reordering supplies as needed, checks supply for expiration dates regularly and prior to use. Completes all department forms, logs and records daily. Adheres to aseptic practices to establish and maintain sterile files, continuously monitors and protects the sterile field, Identify and report breaks in technique 100% of time. Adheres to P/P of sterilization of instruments and equipment and has solid knowledge base of sterilizers. Creates and maintains sterile field as evidenced by continuous monitoring and protection of sterile field with identification of any breaks in technique 100% of time. Accurate scheduling of surgical procedures per P/P. Accurately handles, labels and records all tissue specimens in accordance with P/P, and demonstrates a working knowledge of specimen collection, proper handling, labeling, and submitting to appropriate departments.

Directs and assists in counting of sponges, sharps and instruments per P/P. Assist Anesthesia during induction/emergent phase and other times as indicated and attaching proper monitoring devices as necessary.

Possesses Job Knowledge of Pediatric Assessment and Care: Utilizes knowledge of pediatric growth and development stages to assist aid with ongoing assessment and performance of care for the pediatric patient. Demonstrates ability to recognize early complication development. Demonstrates ability to obtain equipment/supplies to assist the surgical team/providers. Performs and documents patient/family teaching. Recognize and reports appropriately high-risk social situations.


Competency: Assist in Surgical Procedures: Maintains patient safety per departmental policy. Assist with unit surgical procedures per operating room standards and departmental policy. Accurate labeling of surgical specimens per departmental policy. Demonstrates understanding and knowledge of all surgical equipment: Purpose, Safety guidelines and supplies. Prepares instruments for sterilization per operating room standards and departmental policy. Adheres to P/P of sterilization process with solid knowledge base of the sterilizers: Steam, IUSS, Steris, H2O2 Facilitates exchange of instruments to ensure adequate quantities are available on unit.

Competency: Performs Surgical Skills: Demonstrates ability in performing care for patient with any medical/surgical interventions and/or equipment. Demonstrates ability to locate emergency equipment. Demonstrates ability to perform surgical skin preparations. Communicates with patient in positive manner that meets the age-specific needs of the patient. Assesses the health status of patients in a systematic and continuous manner. Documents health status data on patient care record/EMR if applicable


Promptly report to the physician any abnormal findings which may complicate the procedure or reduce the probability of achieving the desired outcome given the current state of knowledge. Demonstrates through knowledge of surgical skills for all areas of department including pre-operative, intra-operative, recovery, and secondary recovery. Demonstrates proper usage and protocols for electrocautery and cautery device. Monitors all patients carefully by using observation skills and monitoring of appropriate vital signs. Maintains patient care standards as set forth by regulatory agencies, ASPAN, AORN, CLIA, DNV, AAMI, AABB and CMS.

Communicates all pertinent patient information to nurse manager, RN-1, physicians, offices, and other pertinent personnel.


Knowledge of Role: Code Blue, Trauma: Alpha, Bravo and Code Pink competency.

Competency: Provides Emergency Assistance: Responds to request for emergency assistance, assists in disaster management, assisting with clearing hallways, and rooms. Ordering stat emergency test as indicated by provider. Surgical Fire: Location of fire pulls /extinguisher/fire exits. PASS: Pull-Aim-Squeeze handle -Sweep at base; RACE: Rescue -Alarm-Contain- Extinguish/Evacuate; Crash cart-location & retrieval; Malignant Hyperthermia cart location and retrieval; Role: Disaster, Emergency Code (Code Blue, Code Silver, Doctor Storm etc.) and Incident Command