Registered professional nurse who assesses, implements or delegates, plans, and evaluates total nursing care and functions in accordance with established philosophy, providing and directing patient care for a group of patients. Relates effectively with other shifts/departments for optimal continuity of care. Provides clinical supervision for entry level nurses and assists in their development.
1. Uses critical thinking skills to assess the basic physical, psychological, social, cultural, spiritual, and developmental needs of patients and families. Communicates findings to appropriate healthcare team members.
a. Collects data from all applicable resources; organizes assessment data so that it is complete and accessible; and then documents findings (legibly) in the medical record or other appropriate documents.
b. Recognizes alterations in health status, anticipates onset of patient care crisis situation and communicates findings appropriately.
c. Assesses, reassesses, and manages pain.
2. Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practices. Implements patient care and therapeutic procedures. Monitors and documents progression of treatment and teaching goals.
a. Identifies and prioritizes the patient’s present/potential problems.
b. Plans appropriate nursing interventions specific to the patient’s problems, incorporating the patient’s cultural, age-specific, and developmental needs.
c. Competently performs nursing interventions and procedures for the patient population (s) served consistent with scientific principles of nursing and policy and procedure.
d. Provides education to patients and family concerning diagnosis, treatment, and hospitalization.
e. Reviews and updates plan of care according to patient’s needs and/or regulatory agency requirements.
f. Documents and involves patient, family, and other healthcare workers in plan of care decisions in accordance with HIPAA requirements.
3. Evaluates the care and treatments provided to the patient and the patient response to the care and treatments. Performs timely re-assessment and documentation:
a. Evaluates patient’s response to treatment/care and modifies plan of care as needed.
b. Evaluates patient and/or significant others ability to perform self care and procedures prior to discharge.
c. Records patient’s response to prescribed treatment and other significant data.
Patient Throughput/ Patient Flow Process
1. Anticipates admission/discharge/transfer needs to facilitate patient flow.
a. Identifies potential/actual discharge/transfer needs of patients upon admission and as patients’ conditions change.
b. Identifies need for and/or follows-up on referrals to ensure identified problems are addressed.
c. Incorporates other disciplines into plan of care according to patient’s needs.
d. Evaluates patients and/or significant other’s understanding of discharge instructions based on ability to verbalize and/or give return demonstration.
e. Expedites admission/discharges/transfers.
f. Participates in a process of communication with the multi-disciplinary team to facilitate the progress of the patient through the continuum of care.
1. Demonstrates good stewardship in proper use and maintenance of equipment and supplies.
a. Coordinates the selection of supplies and equipment in a cost effective manner.
b. Charges for supplies/procedures appropriately.
c. Ensures availability and organization of supplies and equipment for patient care.
d. Performs and documents emergency equipment checks as assigned.
e. Removes and returns discontinued supplies and equipment.
f. Removes broken equipment from area immediately and initiates a work order.
g. Ensures and documents that all alarms (patient and equipment) are functional.
Safe Practice/ Quality Care/ Regulations
1. Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes.
a. Demonstrates accountability for nursing research and quality improvement Activities.
b. Demonstrates knowledge and skill in administering medications.
2. Completes medication reconciliation upon admission, transfer, and discharge.
3. Reviews physician’s orders for clarity and accuracy, legibility & appropriate authenticity (name, title, date, time, etc.).
4. Follows the restrictions on abbreviations and does not use abbreviations on the “Do Not List”. Uses only approved abbreviations.
5. Transcribes telephone orders per policy.
6. Administers, documents, and evaluates medications according to policy and procedure.
7. Instructs patient on medication including: expected effects, side effects, and possible food or medication interactions and documents instructions.
8. Recognizes, reports, and documents medication errors and adverse drug reactions.
a. Uses patient identifiers as defined by policy.
b. Communicate patient information effectively across the continuum of care.
9. Uses an approved hand-off communication format consistently.
10. Follows the universal protocol, e.g. time out.
11. Uses SBAR to communicate changes in patient condition.
12. Follows the Chain of Command.
13. Critical values are reported in a timely manner in accordance with policy.
14. Sets clinical alarms according to equipment parameters and responds rapidly to the alarms.
a. Initiates the Rapid Response team in response to deterioration in patient condition.
b. Demonstrates safe patient handling practices.
c. Promotes a safe patient care environment including compliance with restraint policy and rounding.
d. Implements processes to prevent falls, pressure ulcers, and other hospital-acquired complications.
e. Assures compliance with core measure implementation and documentation, e.g. SCIP, CHF, AMI, CAP.
f. Identifies, corrects and/or reports patient safety and/or environmental safety hazards at the time of discovery.
g. Demonstrates proper infection control and isolation techniques including providing appropriate information concerning isolation precautions and patient status to patient, family, and/or significant others and/or other disciplines.
h. Adheres to CHRISTUS policies and procedures and the standards of the Joint Commission, OSHA, DHHS, HIPAA, etc.
1. Serves as a leader of patient care.
a. Guides and supervises other nursing staff in the operational activities in assigned area.
b. Promptly recognizes and attempts to reinforce appropriate behavior and attempts to correct inappropriate behavior in self and co-workers.
c. Delegates nursing and non-nursing functions according to standards.
d. Participates in leadership activities including community activities, e.g. charge/team leader, council participation, preceptor/coach, unit education, staff/council meetings.
e. Assumes responsibility for currency of knowledge and skills including participating in unit-level meetings and all mandatory education activities sponsored by the facility.
f. Identifies and corrects inconsistencies in nursing procedures/techniques.
g. Participates in implementing performance improvement and change activities.
h. Assists in teaching and evaluating other personnel as assigned.
i. Contributes to the learning experience of students and new employees.
j. Acts as a resource person.
k. Communicates the intensity of work load and collaborates with nursing leadership to meet patient care needs and unit activity.