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Team Leader Registered Nurse (RN) - EP High Call

Deaconess Clinic Downtown

  • Newburgh, IN
  • 9 days ago

    Highlights

    Assessments indicate knowledge and understanding of the complete medical plan of care including but not limited to treatment goals, orders, pertinent diagnostics and laboratory results, ancillary care plans, interventions, and discharge plans. Documentation is accurate; timely; clinically relevant; and reflects the patient's status, care given and clinical impressions (ANA Principles of Nursing Documentation 2010).

    Numbers & Facts

    LocationNewburgh, IN

    Description

    • Must be able to demonstrate knowledge of growth and development to provide patient care appropriate to the age of the patients served.
    • Successfully demonstrates the staff requirements as specified in the specific Care Centers Scope of Service, and complete the Care Centers specific competencies, and meet/exceed the Care Centers standards as identified below.
    • Adheres to and implements the American Nurses Association Standards of Practice and Standards of Performance as identified by: Assessment Problems/Diagnosis Identification of Outcomes Planning Implementation Evaluation Quality of Care and Administrative Practice Performance Appraisal Performance Knowledge Performance Environment Ethics Collaboration Research Resource Utilization
    • Adheres to and implements the American Nurses Association Bill of Rights by establishing and maintaining workplace expectations and environments which support sound professional nursing practice.
    • Nursing Process:Assessment: Assessment is based on relevant physical, emotional, developmental, social, cultural, spiritual, and sexual data to identify needs and determine real and/or potential patient risks. Assessments indicate knowledge and understanding of the complete medical plan of care including but not limited to treatment goals, orders, pertinent diagnostics and laboratory results, ancillary care plans, interventions, and discharge plans. Collaborates and communicates with multidisciplinary team members regarding patient needs based on assessment. Assessment process demonstrates individualization, clinical knowledge and judgment, critical thinking, prioritization, and patient-centered care. Assessment identifies risk management and safety issues for each patient. Identifies and communicates risks to the multidisciplinary team members. Nursing Diagnosis: Utilizes clinical knowledge and judgment to identify and document nursing diagnoses related to patient plan of care. Nursing diagnoses are prioritized based on a comprehensive assessment and communicated to the multidisciplinary team members on an ongoing basis. Planning and Outcomes: Develops and communicates an individualized plan of care with realistic measurable goals, appropriate to age and cultural needs, in collaboration with the multidisciplinary team and patient/family/significant other. Revises plan of care based on changes in patient's condition/assessment, input or feedback from patient and/or family, achievement of objectives or goals. Seeks consultation and/or utilizes the multidisciplinary team to assist in the planning for patients with complicated or complex needs. Implementation: Conforms to legal requirements, the state nurse practice act, and the hospital/departmental policies and procedures. Performs nursing interventions and technical skills according to practice and performance standards. Demonstrates knowledge and proficiency in daily nursing responsibilities. Seeks guidance, consultation, or assistance in providing nursing care and skills which are utilized infrequently. Nursing interventions demonstrate application of appropriate evidence-based learning theories, concepts and/or principles. Delegates responsibilities appropriately to multidisciplinary team members based on the patient's needs, and the team members job description, competency, and workload (ANA Principles of Delegation 2005). Demonstrates calming techniques and approaches with persons who are upset, angry, disruptive, Takes steps to diffuse problematic situations. Involves Patient Relations as appropriate. Reports problematic situations to charge nurse/nurse manager. Demonstrates accountability for nursing care by incorporating evidence-based practices. Continually evaluates best practices to provide excellence in nursing care. Utilizes the six Rs when administering medications: right patient, right drug, right dose, right route, right time and right documentation. Evaluation: Consistently evaluates patient outcomes and revises the plan of care accordingly. Documents updated plan of care daily. Involves the patient/family/significant other and multidisciplinary team when assessing the plan of care in order to evaluate outcomes. Documentation and Unit and Advanced Competencies: Demonstrates competencies listed in the Appendix. Completes prescribed education and training to maintain and verify basic and advanced skills. Documentation is accurate; timely; clinically relevant; and reflects the patient's status, care given and clinical impressions (ANA Principles of Nursing Documentation 2010). Utilizes electronic medical record appropriately. Keeps documentation on review, investigation, action plan, patient and employee outcomes to illustrate timelines of events and expected outcomes. Safety and Quality: Attends all required safety training programs and can perform responsibilities related to safety. Responds appropriately to safety questions and knowledgeable of unit resources. Operates equipment and performs all procedures in a safe manner. Follows the hospital infection control and exposure plans. Demonstrates correct use of personal protective equipment. Recognizes and takes responsibility to correct safety hazards. Communicates adverse event through the appropriate reporting chain of command. Completes incident reports in a timely manner. Accepts responsibility for and contributes to the success of core measures. Actively participates in increasing patient satisfaction score. Supports nursing shared governance activities for the pursuit of excellence in nursing care. Identifies and communicates opportunities for improvement. Goals: Employee provides suggestions/goals on self-evaluation that are actionable and measurable. Goals submitted are tied to department or organizational goals. * Submits at least one growth/development goal.

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