Ambulatory Care Nurse, Lead

Registered Nurse/Ambulatory
The Registered Nurse/Ambulatory is a member of the multidisciplinary team working in collaboration with the physician. The RN utilizes the care process consistent with their license or certification including initiation of interventions within individual scope of practice. The RN is also responsible for overseeing any necessary coordination of the multidisciplinary plan of care and provides for its consistency with the medical treatment plan. The patient care process includes:

Assessment- an orderly process consisting of the identification, gathering and organization of subjective and objective data pertaining to the patient/family/significant other.
Planning- an organized step in the process that consists of the identification of the actual or potential problems and desired outcomes (goals) that result in a documented plan of care. The plan of care provides direction for the patient/family/significant other.
Intervention- the specific interventions or orders that are implemented consistent with the plan of care and medical treatment plan.
Evaluation- a step in the process that involves determining the effectiveness of the interventions in achieving the plan of care and determining the conclusions concerning the need for reassessment and revisions to the problems, goals, plan of care, and interventions. Patients have problems identified and prioritized relative to biophysical, psychological, environmental, self-care, educational and social status.
Goals are identified consistent with the problem to provide direction for patient care and health promotion.