Under general supervision, following established policies, procedures, and professional guidelines, delivers nursing care to patients. Plans and implements nursing care; documents nursing assessments; identifies and reports situations requiring further intervention; formulates and communicates goal-directed plan of care; assures patient rights. Responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital and principles of quality improvement
Essential Functions
- Assesses and analyzes the health status of patients in assigned nursing unit in a comprehensive manner. Performs and/or assures completed assessments on all patients admitted within the designated time delineated in policy/unit standards.
- Performs on-going assessments and documents according to policy and procedure, reports significant findings of admission and on-going assessments to appropriate member of heath care team.
- Initiates discharge planning process with initial admission assessment.
- Plans patient care on assigned unit in collaboration with the patient, family, and health care team.
- Formulates individualized patient plan of care based on assessment data within the designated time delineated in policy/unit standards.
- Updates plan of care based on the patient assessment within appropriate time period.
- Directs, implements and coordinates patient care activities on assigned unit to ensure the delivery of quality care.
- Communicates the plan of care to other members of the healthcare team through daily worksheet conferences, verbally during the shift and shift report.
- Directs care team members in accordance with their scope of practice.
- Communicates and documents all patient care given including assessments, plan of care, interventions, patient response, and follow-up. Transcribes and directs the implementation of physician orders. Provides patient education based on assessed needs and evaluates understanding.
- Conducts ongoing evaluation of patient outcomes and documents effectiveness of planned and implemented interventions and strategies in relation to the plan of care within time frames per policy/unit standards. Includes patient and family in the evaluation process.
- Provides appropriate patient assessment and care specific to the needs of the patient populations served (e.g. age groups, patients of size; diagnosis-based).
- Demonstrates knowledge and awareness of the specific physical, psychosocial and developmental needs of patients as appropriate to the populations served.
Education Qualifications
- Associate's Degree Nursing
Licenses and Certifications
- Registered Nurse
- Basic Life Support (BLS) through American Heart Association or American Red Cross
Experience Qualifications
- Unit specific certifications may be required.
- May include but not limited to:Advanced Cardiovascular Life Support (ACLS)Pediatric Advance Life Support (PALS)STROKENational Institutes of Health Stroke Scale (NIHSS)STABLE
Skills and Abilities
- Knowledge of assessment techniques and diagnostic tools.
- Ability to conduct thorough assessments, interpret clinical data, and apply critical thinking to respond to changes in patient condition.
- Knowledge of evidence-based practices for care planning.
- Skill in developing, implementing, and modifying patient care plans in collaboration with the healthcare team, ensuring effective care coordination.
- Understanding of patient education principles and ability to provide clear, personalized education to patients and families and assess their comprehension to ensure understanding and compliance.
- Knowledge of outcome measurement and quality improvement processes.
- Ability to evaluate patient progress and adjust care plans based on patient responses, contributing to ongoing improvement initiatives.
- Familiarity with healthcare documentation standards and legal requirements.
- Ability to document patient care accurately and timely, ensuring compliance with legal, ethical, and institutional standards.