Essential Job Functions:
1. Obtains nursing history from available sources including the patient, the chart, other nursing personnel and the physician. Differentiates between normal/ abnormal findings. Utilizes nursing history to make an assessment of patient’s condition, and individualizes plan of care. Anticipates, recognizes, and reports changes to the appropriate person(s). Monitors patient data and determines it
effect on the patient’s progress and the nursing care plan.
2. Documents findings and actions clearly including assessment of the patient and use of safety measures. Makes certain physician’s orders are given and/or completed and all other reports and charges are documented according to policy. Makes certain that charting is thorough and complete.
3. Establishes priorities in providing care for the patient assignment and re-establishes priorities to accommodate changes in the patient’s status and the unit’s operation. Assists with/supervises procedures, equipment set-up and troubleshooting as necessary. Reviews overall nursing care program for the department and determines effectiveness in meeting established care goals.
4. Adapts to changing unit environment, i.e., volume, triage levels and acuity, staffing, etc. Functions as a resource person for less experienced personnel and unit preceptors. Sets up and teaches in-service programs to support the department and to complement overall staff education.
5. Assures that all employees are involved in process improvement actively seeking to improve and refine processes within the department in accordance with System, facility and unit initiatives. Supports hardwiring processes, validating and coaching staff when appropriate and necessary (ex.
Hourly rounding, AIDET, quality initiatives, Core Measures, CPOE, eMAR, Unit Based Staff Practice Council participation, etc.)
6. Coordinates patient and room assignments, along with resources and needs, considering needs/abilities of employees available for assignment.<...
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