Job Summary Responsible for the planning and delivery of care utilizing nursing processes\: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem solving strategies and applies evidence based practices. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director. Provides compassionate and family centered care. Job Specific Duties Ensures completion of patient admission, history, assessment, & pain reassessment. Accurately prepares & completes the discharge planning process per department and hospital policies & procedures. Conducts handoff with oncoming RN utilizing SBAR; documents in Cerner. Conducts assessments and documents. Plans, implements, and documents the plan of care (i.e. high risk of falls) in collaboration with other disciplines and services to assure safe and efficient care. Provides nursing care that includes\: IV site monitoring, suctioning, specimen collection, lines, tubes and drains, and assists medical team with specific procedures. Follows physician’s orders and administers medication. Adheres to six rights of medication administration. Collaborates and rounds with a multi-disciplinary team during daily care planning rounds as appropriate and fosters a Family Centered Care Environment. Utilizes electronic innovations to provide efficient patient care. Attends to patient call lights in a manner that promotes patient safety per hospital policy. Reports critical values or change in status to the physicians within Procedure and Policy Standards and documents clinician notification in Cerner. Ensures proper and safe wound care as required by Wound Care Policy and Procedures. Accesses electronic health record independently according to hospital policy. Completes accurate and timely documentation in the patient’s electronic health record. Communicates with patients and families to review plan of care, provide education, and when necessary uses appropriate translation methods. Communicates any patient and family concerns to physician. Promotes an “error free” working environment by consistently providing high-quality safe care as per hospital policies. Responsible for providing a safe environment for co-workers by placing isolation/precaution signs (droplet, contact, or airborne). Creates incident reports for hospital acquired conditions, near misses, malfunction of machine on patients, and adverse events/medication errors documenting the situation within 72 hours. Assesses all body systems, ensures safe efficient care, absence of medication errors, avoidance of falls, prevention of central line infections, ouch-free procedural pain, and pain reduction.
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Job Type
Full-time
Education Level
No Education Listed