Position Summary - Basic Job Function and Responsibilties Overview

To assume the responsibilities and accountability of a clinically proficient nurse for promoting and assuring patient centered care. To integrate professional abilities for the overall planning, delivery, coordination, and evaluation of patient care.

Job Duties

Obtains a comprehensive admission history, performs physical assessment per unit policy and demonstrates integrated assessment abilities. a. Differentiates variations of normal and abnormal assessment findings. b. Analyzes and prioritizes abnormal findings. Initiates appropriate response. c. Anticipates actual or potential problems or health concerns in the hospital and/or home setting.

Demonstrates ongoing assessment of patient’s psychosocial, physiological, and educational process per unit policy. a. Anticipates, recognizes, and documents subtle changes in patient’s physical and mental status. b. Integrates analysis of diagnostic information in patient assessment and care. c. Analyzes ongoing assessments to determine patient’s and/or significant other’s learning and discharge needs.

Integrates assessment data and formulates an individualized nursing diagnosis according to the Department of Nursing’s policies and procedures.

Formulates an individualized plan of care based on standards of care and practice and hospital/unit policies. a. Identifies and focuses on the physical, emotional, spiritual, cultural, learning and discharge planning needs of the patient and significant other(s). b. Develops, interprets, and correlates realistic goals and orders which will maintain or improve patient health status. c. Discusses and disseminates information concerning patient plan of care with members of the interdisciplinary health care team. d. Participates in ongoing discharge planning with members of the interdisciplinary health care team.

Modifies individualized plan of care based on ongoing assessment and changes in patient status. a. Re-evaluates current goals and priorities for action. b. Appropriately coordinates holistic care. c. Anticipates and manages changing situations.

Administers prescribed treatments and medications promptly according to hospital policies and procedures.

Guides and provides functional supervision of ancillary staff while maintaining accountability for patient care. Assists and guides peers with patient care decisions.

Recognizes and questions unsafe, incorrect, or inadequate orders. Intervenes to clarify patient order.

Utilizes opportunities during the delivery of patient care to teach the patient information necessary to attain the optimal level of self-care. a. Recognizes patient’s readiness to learn. b. Develops and enhances an individualized teaching plan in conjunction with the patient’s needs. c. Utilizes available teaching materials and support groups, etc.; formulates instructional material as needed. d. Reinforces teaching done by other members of the interdisciplinary health care team.

Evaluates patient’s responses to care and comprehension of education. a. Monitors response to intervention and progress towards goals. b. Evaluates the effectiveness of patient care provided by ancillary nursing personnel.

Documents all aspects of the nursing process in a legible, concise, clear, and timely manner utilizing appropriate hospital forms or technology and terminology.

Involves patient and significant other(s) in all aspects of the nursing process. a. Acts as a patient advocate and respects the rights and confidentiality of patients. b. Promotes communication and relays information in a clear manner. Utilizes information and communication systems effectively. c. Understands and acts within the guidelines for addressing ethical concerns.

Demonstrates sound judgment with the Nursing Process based upon critical thinking skills and a problem solving approach. a. Organizes, prioritizes and demonstrates accountability for nursing care. b. Demonstrates sensitivity to strengths and limitations of peers. Offers praise, direction and evaluation as needed. c. Recognizes own limitations, seeks assistance and takes corrective action as needed.

Anticipates and takes proper action in emergency and complex patient care situations.

Participates in performance improvement activities and utilizes recommendations in patient care delivery.

Understands and acts within the guidelines as defined in the Department of Nursing organizational structure. Utilizes chain of command and appropriate communication procedures.

Performs other related duties as assigned.