Job Summary
This position assesses, plans, implements, evaluates and documents nursing care of patients in accordance with organizational policies and in accordance with standards of professional nursing practice utilizing the framework for professional nursing practice and development. This position is accountable for the quality of nursing services delivered by self or others who are under their direction. This position utilizes specialized knowledge, judgment, and nursing skills necessary to assess data and plan, provide and evaluate care appropriate to the physical and developmental age of assigned patients.
Essential Functions
Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs. Reviews patient history and physical with patient/family and assures completion within appropriate timeframe. Reviews available information obtained by other health care team members. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and as outlined in policy.
Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care. Goals for patient are realistic, measurable and developed in conjunction with the patient/family. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient in the plan of are. Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patients status.
Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team. Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements. Delegates appropriately, and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient's response and the effectiveness of patient teaching.
Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy. Documentation reflects objective/subjective data, nursing interventions and patients response to treatment. Notes physician orders accurately and in a timely manner.
Provides care based on the best evidence available and may participate in research activities within clinical practice. Participates in unit or facility shared leadership. Interacts and participates in the education, role development, and orientation of facility personnel, patients, students, families and visitors. Promotes/supports growth of others through precepting and mentoring when appropriate.
Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Actively participates in the improvement of national nursing quality indicators and outcomes. Such activities may include participating in professional organizations.
In some roles, this position may supervise staff and work flow of the department.
Minimum Qualifications
Must possess a current, valid RN license in state of practice, temporary RN license in state of practice, or compact RN licensure for current state of practice. BLS certification is required. Additional certification or continuing education may be required based on area of practice.
Relates throughout the interview process the experience, training and education needed to perform the job. Experience in the clinical area for which he or she is applying is desired. Must maintain clinical performance competencies appropriate to the area in which they work as demonstrated through annual validations. Banner Registry and Travel acute care positions require a minimum of one year experience in an acute care hospital setting. Experience must include working in an acute care setting within the past 12 months as a Registered Nurse in the specialty area. Banner Registry and Travel physician practice positions require a minimum of one year experience as a Registered Nurse in a physician practice or an acute care setting.
Preferred Qualifications
Bachelors degree preferred.Professional certification preferred.
Additional related education and/or experience preferred.
