RN MED-SURG

Job Description

Job Description

POSITION SUMMARY:

The Registered Nurse provides professional nursing care by utilizing the nursing process to care for patients within an assigned unit. Coordinates care provided throughout the hospital. Cooperates with other members of the health care team in meeting the total needs of patients. Participates in patient education. Directs and assists in activities of ancillary personnel.

ESSENTIAL FUNCTIONS:

1. Utilizes the nursing process of assessment, nursing diagnosis, plan, intervention and evaluation. Prioritizes, plans, and organizes the delivery of comprehensive nursing care.

a. Assess the physiological, psychosocial, educational and discharge planning needs of the patient and family according to nursing policy and procedure.

b . Formulates expected outcomes for each nursing diagnosis which are realistic, measurable, and mutually set with the patient and family and developed as per policy of the unit.

c . Develop patient-specific nursing interventions that are based upon the nursing diagnosis and expected outcomes.

d. Develops, implements, changes, and evaluates Patient Care Plan as evidenced by documented review and revision every 72 hours or as needed.

e . Works with the physician to identify patient goals and nursing interventions.

2 . Maintains a positive and caring interpersonal relationship with patients, families, and fellow employees. Accepts constructive criticism to improve self and nursing practice.

3. Demonstrates technical/clinical skills to provide nursing care that is appropriate for the department assigned. Use good judgment in emergency measures.

4. Able to adapt to change with the workload. Works independently with minimal supervision. Acts as an advocate for patient rights by initiating and maintaining confidentiality, privacy, safety, patient education, and active collaboration with the health care team to promote the patient's best interests.

5. Accountable for assignments and their completion within scheduled work hours. Maintains appropriate time records.

6 . Assists in orientating new staff members as needed. Functions as a clinical resource to LVNs, CNAs/ NAs and Technicians from ancillary departments.

7. Supports, promotes, and functions within the Hospital and Unit policies and procedures and the Nurse Practice Act. Willing to cross-train.

8. Demonstrates proficiency in managing resources and safely utilizing equipment. Actively contributes to cost control by managing time, resources, and supplies effectively.

9. Administers and controls narcotics and medications including parenteral and blood components.

10. Attends 75%, a minimum of six, unit staff meetings annually to be successful. Accountability for reading minutes of monthly meetings. Participates in conferences and education programs required (annual skills update) and quality improvement activities and issues that monitor to improve care provided.

11. Cross-trains to an additional unit or area within 1 year of hire as staffing permits. If requested, will float to another area with documented competency on an already scheduled shift.

OTHER RESPONSIBILITIES:

1. Assesses and cares for the geriatric patient with knowledge and clinical skills of the aging process.

2. Utilizes the chain of command in situations where resolutions of the issues exceed authority.

3. Maintains accountability of own practice and demonstrates professional skills through self-development and participation in ongoing hospital in-service education.

4. Demonstrates knowledge and the ability to apply ethical and legal principles to practices.

5. Communication:

a. Clearly and accurately communicates pertinent aspects of the patient's care to other members of the Patient Care Team.

b . Documentation in patient records will be problem-oriented and will provide relevant, factual, and accurate information.

c. Documentation in the Patient Record will be legible at all times. Entries in the patient record will be dated, timed, and signed with a title.

6. Supports and promotes safety standards, identifies risk situations, and intervenes appropriately.

7. Demonstrates clinical competence by successful completion of the Annual certification of standardized procedures. Current knowledge of Universal Precautions in dealing with potential exposure to Bloodborne Pathogens.

8. Department-specific functions related to quality control are required for Medical/Surgical.

These functions relate to the operation and maintenance of equipment supplies and pharmaceuticals.

9. Other duties as assigned from time to time.

SUPERVISORY RESPONSIBILITIES:

1. Will work under the responsibility of the charge nurse.

1. The Department Charge Nurse has overall responsibility for shift assignments and emergencies

2. The Department Director is responsible for the long-term schedule, performance appraisal (with input from other team members), and quality management issues related to patient care, facility, and in-service needs.

EDUCATION, KNOWLEDGE, EXPERIENCE & SKILLS:

1. Previous clinical experience in a patient care setting preferred, with successful completion of orientation and training to the point of competence.

LICENSES AND CERTIFICATIONS:

1 . Must have current licensure to practice registered nursing in the State of California.

2. Current AHA BLS required upon hire. ACLS certification as required by Med/Surge Department.

AGE OF THE POPULATION SERVED:

1. Adult  Geriatric 

PHYSICAL REQUIREMENTS:

1. Manual dexterity with fine motor ability to operate and handle equipment used in the department.
2. Must be able to lift 25 pounds and able to perform tasks of lifting, turning, and transferring patients.

MENTAL REQUIREMENT:

Ability to follow written and oral instructions must have the ability and desire to learn job functions outlined in the job description, must work as part of a team to achieve a common goal, and must maintain effective work relationships with those contacted in the course of work.

SCHEDULING AND AVAILABILITY:

1. Scheduling is determined by patient care needs and includes weekends, holidays, nights, calls, etc...

2. Working every other weekend is a minimum requirement.

3. Shift and call assignments are modified to reflect department needs.

4. In staff emergencies, we will be able to work on alternate shifts and/or rotating job schedules or similar activities, at intervals for limited periods as mandated by department needs.