RN Med/Surg -Charge Nurse Role

# RN Med/Surg -Charge Nurse RoleHarrisonville, MO 64701## OverviewPosition TypeFull TimeJob ShiftNightEducation Level2 Year Degree## DescriptionDepartment Name: Med Surg Title: Charge RN EEOC Classification: Non-Exempt **Dimension and Description****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= 50% - 74%, 1= <49% annually.**ESSENTIAL PHYSICAL REQUIREMENTS**TYPE OF WORK (Check One) Sedentary Work: Lifting 10lbs maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Jobs are sedentary; if walking and standing are required only occasionally. Light Work: Lifting 20lbs maximum with frequent lifting and/or carrying of objects weighing up to 10lbs. Even though the weight lifted may be only a negligible amount, a job is in this category when it requires walking or standing to a significant degree or pushing and pulling of arm and/or leg controls. Medium Work: Lifting 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 25lbs. x Heavy Work: Lifting 100lbs maximum with frequent lifting and/or carrying of objects weighing up to 50lbs. Very Heavy Lifting: Lifting objects in excess of 100lbs with frequent lifting and/or carrying of objects weighing 50lbs or more. **PHYSICAL DEMANDS (Check those which apply)**x Lifting: Raising or lowering an object from one level to another (includes upward pulling). x Carrying: Transporting an object, usually holding it in hands or arms or on the shoulders.x Pushing: Exerting force upon an object so that the object moves away from the force (including slapping, striking, kicking, and treadle actions). x Pulling: Exerting force upon an object so that the object moves toward the force (includes jerking). Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, ropes, and the like, using the feet and the legs and/or hands and arms. Balancing: Maintaining body equilibrium to prevent falling when walking, standing, crouching, or running on a narrow, slippery, or erratically moving surfaces; or maintain body equilibrium when performing gymnastic feats. x Hearing: Ability to determine audible communication. x Stooping: Bending the body downward and forward by bending the spine at the waist. x Kneeling: Bending the legs at the knees to come to rest on the knee or knees. x Crouching: Bending the body downward and forward by bending the legs and spine. Crawling: Moving about on the hands and knees or hands and feet. x Reaching: Extending the hands and arms in any direction. x Handling: Seizing, holding, grasping, turning, or otherwise working with the hand or hands (fingering not involved). x Fingering: Picking, pinching, or otherwise working with the fingers primarily (rather than with the whole hand or arms as in handling). x Repetitive Motions: Substantial movements (motions) of the wrist, hands, and/or fingers. x Feeling: Perceiving such attributes of objects and materials as size, shape, temperature, or texture by means of receptors in the skin, particularly those of the finger tips. x Speaking: Expressing or exchanging ideas by means of the spoken word. Those activities in which they must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. x Seeing: Obtaining impressions through the eyes of the shape, size, distance, motion, color or other characteristics of objects. Including Major Visual Functions x Acuity, far - clarity of vision at 20 feet or more. x Acuity, near - clarity of vision at 20 inches or less. x Depth perception - ability to judge distance and space relationships so as to see objects where and as they actually are. x Field of vision - area seen up and down or to the right or left while eyes are fixed. x Accommodations - adjustment of the lens of the eye to bring an object into sharp focus. x Color vision - the ability to identify and distinguish colors.**WORKING CONDITIONS (Check those which apply)**x Inside: Worker spends approximately 75% or more of time inside. Outside: Worker spends approximately 75% or more time outside. In/Outside: Activities occur inside or outside in approximately equal amounts. Extremes of Cold: Temperature sufficiently low to cause marked bodily discomfort unless worker is provided with exceptional protection. Extremes of Heat: Temperature sufficiently high to cause marked bodily discomfort unless worker is provided with exceptional protection. Temperature Changes: Variations in temperature which are sufficiently marked and abrupt to cause noticeable bodily reactions. x Wet: Contact with water or other liquids. Humid: Atmospheric condition with moisture content sufficiently high to cause marked bodily discomfort. Noise and Vibration: Sufficient noise, either constant or intermittent to cause marked distraction or possible injury to the sense of hearing and /or sufficient vibration (production of an oscillating movement or strain on the body or its extremities from repeated motion or shock) if endured day after day. x Hazards: Situations in which the individual is exposed to the definite risk of the bodily injury. Fumes: Smoky or vaporous exhalations, usually odorous, thrown off as the result of combustion or chemical reaction. Odor: Noxious smells, either toxic dust, fumes, gases, vapors, mists or liquids which cause general or localized disabling conditions as a result of inhalation or action to the skin.Toxic Conditions: Exposure to toxic dust, fumes, gases, vapors. Mists or liquids which cause general or localized disabling conditions as a result of inhalations or action to the skin. x Infectious Disease: Risk of exposure to biohazardous materials, blood, body fluid contamination.Dust: Air filled with small particles of any kind, such as textiles dust, flour, wool, leather, feathers, etc., and inorganic dust including silica and asbestos, which make the workplace unpleasant or are the source of occupational disease. Poor Ventilation: Insufficient movement of air causing a feeling of suffocation; or exposure to drafts.Identify and describe any additional physical demands or unusual working conditions that were not previously covered. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ #J-18808-Ljbffr