Preference will be given to those with EPIC patient charting experience POSITION SUMMARY Responsible to the Unit Manager for the overall nursing practice of the unit during the shift assigned. In the absence of the Unit Manager, the RN is responsible to the Nursing Supervisor, Charge Nurse or the Nursing House Supervisor of the shift. Provides professional nursing care based on current nursing knowledge through use of the nursing process. This includes the responsibility for assessment of the patient's needs, development of the plan of care to meet those needs, implementation of nursing measures and evaluation of the effectiveness of the nursing care and other treatment measures. ESSENTIAL FUNCTIONS The Nurse Collects Patient Health Data by:Prioritizing data collection based on the patient's immediate condition or needs.Collecting pertinent data using appropriate assessment techniques based on the patient's and family s developmental levels, health status and identified learning needs.Involving the patient, significant others, and other health care providers when appropriate in data collection.Using a data collection process that is systematic and ongoing.Documenting relevant data in a retrievable form. The Nurse Analyzes the Assessment Data in Determining Diagnoses that are:Derived from the assessment data.Validated with the patient, significant others, and other health care providers.Documented in a manner that facilitates the determination of expected outcomes and plan of care. The Nurse Identifies Expected Outcomes Individualized to the Patient. Outcomes are:Derived from the diagnoses.Documented as measurable goals.Formulated with the patient and other health care providers when possible.Realistic in relation to the patient's present and potential capabilities.Attainable in relation to resources available to the patient.Attainable within the time estimate established.Directed toward providing continuity of care. The Nurse Develops A Plan of Care that Prescribes Interventions to Attain Expected Outcomes. The Plan:Is individualized to meet the patient's developmental and health status needs.Is developed with the patient, significant others and other health care providers, when appropriate, and considers role relationships and interaction patterns of family members.Reflects current nursing practice.Includes appropriate interventions to meet the patient's and family s identified learning needs.Is documented.Provides for continuity of care including post discharge. The Nurse Implements the Interventions Identified in the Plan of Care. Interventions are:Consistent with the established plan of care.Implemented to prevent potential developmental and health problems in vulnerable patients and at risk families.Directed at assisting patients and families to understand and cope with developmental and traumatic situations during illness.Implemented in a safe and appropriate manner.Documented. The Nurse Evaluates the Patient's Progress Toward Attainment of Outcomes by:Evaluating using a systematic and ongoing process.Documenting the patient's responses to interventions.Evaluating the effectiveness of interventions in relation to outcomes.Using ongoing assessment data to revise diagnoses, outcomes, and the plan of care as needed.Documenting revisions in diagnoses, outcomes, and the plan of care.Involving the patient, significant others, and other health care providers in the evaluation process, when appropriate. The Nurse Systematically Evaluates the Quality and Effectiveness of Nursing Practice by:Participating in quality of care activities as appropriate to the individual's position, education, and practice environment. Such activities may include:Identification of aspects of care and development of indicators used to monitor the effectiveness of nursing care.Collection of data to monitor quality and identify opportunities for improving nursing care.Recommendation and implementation of activities to improve the quality of nursing practice and patient outcomes.Participation on interdisciplinary teams that evaluate clinical practice or health services.Development of policies and procedures to improve quality of care.The nurse uses the results of quality of care activities to initiate changes in practice.The nurse uses the results of quality of care activities to initiate changes throughout the health care delivery system, as appropriate. The Nurse Evaluates His/Her Own Nursing Practice in Relation to Professional Practice Standards and Relevant Statutes and Regulations by:Engaging in performance appraisal on a regular basis, identifying areas of strength as well as areas for professional/practice development.Seeking constructive feedback regarding his/her own practice.Taking action to achieve goals identified during performance appraisal.Participating in peer review as appropriate. The Nurse Acquires and Maintains Current Knowledge in Nursing Practice by:Participating in ongoing educational activities related to clinical knowledge and professional issues.Seeking experiences to maintain clinical skills and demonstrate clinical competency.Seeking knowledge and skills appropriate to the practice setting and related to the designated age specific population(s) served.Updating knowledge and clinical skills on an ongoing basis including but not limited to successful completion and maintenance of Healthcare Provider Basic Life Support (HCP BLS) certification. HCP BLS must be completed within four (4) months of the end of probation. The Nurse Contributes to the Professional development of Peers, Colleagues and Others by:Sharing knowledge and skills with colleagues and others.Providing peers with constructive feedback regarding their practice.Contributing to an environment that is conducive to clinical education of nursing students, as appropriate. The Nurse's Decisions and Actions On Behalf Of Patients Are Determined In An Ethical Manner by:Practicing by the "Code for Nurses" and the "Patient's Bill of Rights".Maintaining patient confidentiality.Acting as a patient advocate.Delivering care in a nonjudgmental and nondiscriminatory manner that is sensitive to patient diversity.Delivering care in a manner that preserves/protects patient autonomy, dignity and rights.Seeking available resources to help formulate ethical decisions. The Nurse Collaborates With The Patient, Significant Others, and Health Care Providers in Providing Patient Care by:Communicating with the patient, significant others and health care providers regarding patient care and nursing s role in the provision of care.Consulting with health care providers for patient care, as needed.Making referrals, including provisions for continuity of care, as needed. The Nurse Uses Research Findings in Practice by:Using interventions substantiated by research as appropriate to the individual's position, education and practice environment.Participating in research activities as appropriate to the individual's position, education and practice environment. Such activities may include:Identification of clinical problems suitable for nursing research.Participation in data collection.Using research findings in the development of policies and procedures and guidelines for patient care. The Nurse Considers Factors Related to Safety, Effectiveness and Cost in Planning and Delivery Patient Care by:Evaluating factors related to safety, effectiveness and cost when two or more practice options would result in the same expected patient outcome.Assigning or delegating care based on the needs of the patient and the knowledge and skill of the provider selected.Assisting the patient and significant others in identifying and securing appropriate services available to address health-related needs.Promoting an environment free of hazards to growth, development, and wellness, and one that promotes recovery from illness. The Nurse Demonstrates Leadership Skills by:Prioritizing and delegating unit and patient care activities, as appropriate.Demonstrating flexibility in a changing health care environment.Assumes other duties and responsibilities related to job classification and department as assigned by the unit director/manager. The Nurse Meets the Specialty Standards of Nursing Practice Applicable to His/Her Primary Area of Nursing Practice. The specialty Standards of Nursing Practice that may apply are:AACNANNAAORNENAINSAWHONNMed-Surg/NAONPsych - Mental HealthONSASPANARN The Nurse participates in the out of facility transport of patients utilizing the nursing process. Reference: ANA Standards of Clinical Nursing Practice Position Urgency:Normal Billing string = Medefis
