Med/Surg RN | Nights (Full Time)

Job Description

Job Description

Key Accountability: Quality Nursing Care

· Receive report at bedside with nurse going off duty. Admit and orientate new patients and family. Check patient identification, physician orders, pre-admission and transfer information if applicable. Make appropriate bed assignments. Take patients medical and social history. Requisition and arrange for ordered diagnostic and therapeutic services. Send diet orders to dietary. Order prescribed medications, patient supplies and equipment. Review the Electronic Medical Record to see that all permits, authorizations, releases and other required forms are completed. Take physician’s orders and place in the EMR. Schedule appointments with other departments and arrange for transport.

· Develop and implement nursing care plans that enhance the effectiveness of the general therapeutic plan for each patient in consultation with supervisor, physician, and/or other ancillary services.

· Plan for patient discharge or transfer. Initiate discharge/transfer process. Initiate referral to social services when needed, i.e. home health, nursing home placement etc.

· Function clinically as staff nurse delivering direct patient care. May also be team lead while functioning in direct patient care role.

· Make hourly rounds to evaluate patient’s conditions, answer questions, give instructions, take vital signs and check the functioning of equipment. Record vital signs and observations. Make rounds and assist physicians during treatments and examinations.

· Prepare and operate equipment. Prepare supplies, cleanse wounds, incisions and change dressings. Prepare and administer prescribed medications. Start, replenish and discontinue intravenous infusions. Perform catheterizations, suctioning, lavage, nasal packing etc. Perform prescribed treatments.

· Observe and record: medications, treatment, patient reactions/response, patient condition, progress of infusions and infiltrations, physical appearance of patients, attitude, appetite, new or change in symptoms. Notify supervisor and/or physician of significant changes in patient’s response to treatment and care, symptoms of infections, disease, stress, reactions to medications etc.

· Float to other clinical areas for assistance in emergencies.

· Recognizes emergencies and responds with proper protocol, i.e. resuscitation, oxygen, emergency drugs, cardiac massage, application of medical equipment etc as established by the Medical Staff.

· Institute nursing measures to prevent patients from developing complications and alleviate discomfort and pain.

· Interpret and explain procedures, regimens and services to patients and families.

· Inform supervisor if standards of care and performance are not being met.

· Assist in planning, supervising, and instructing LPN’s, Aides and students. Demonstrate nursing techniques procedures and assist non-professional nursing care personnel in rendering nursing care.

· Assists LPN’s in performing treatments and giving certain medication.

· Actively participate in team-oriented decision making process. Is a team player, willing to be flexible and open to other’s ideas.

· Focus portion of daily work toward high customer satisfaction. The goal of all employees is to meet or exceed our customer’s expectations 100% of the time.

· Develop a proactive mind set towards the job. Observes opportunities for improvement, formulates ideas, communicates those ideas with their supervisor and/or other staff, and carries out variations in work habits in continuous quality improvement.

· May function in a charge nurse role.

· Perform other duties as directed by a proper authority as indicated in an approved Hospital policy

· Key Accountability: Regulatory and Departmental Policy/Procedure Compliance

· Responsible for adhering to standards, procedures and goals relating to the Compliance Program.

· Expected to report conduct that is known or suspected to be illegal or in violation of the organizational policy. Reporting may be made in person or in writing to supervisor or manager, Compliance Officer or verbally through Compliance Reporting Line (ext.5442).

· Adheres to hospital and department policies, procedures, objectives, safety, environmental, infection control and quality assurance program.

· Maintain all required records, reports, statistics etc.

· Assist in the care and maintenance of department equipment and supplies.

· Attends Meetings as required.

Basic Clarke County Hospital (CCH) Performance Criteria

· Demonstrates Clarke County Hospital Standards of Behaviors as well as adheres to hospital policies and procedures and safety guidelines.

· Demonstrates ability to meet business needs of department with regular, reliable attendance.

· Employee maintains current licenses and/or certifications required for the position.

· Practices and reflects knowledge of HIPAA, DIA, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

· Completes all annual education and competency requirements within the calendar year.

· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.