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24601300Description

Summary

Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients.

Responsibilities

  • Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
  • Patient Care Planning
  • Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment.
  • Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference.
  • Reviews and updates nursing care plan and collaborates with team members as changes occur.
  • Patient Care Provision
  • Implements patient care as planned in nursing care plan and interdisciplinary care plan.
  • Sets priorities based on knowledge of patient acuity and patient needs.
  • Provides safe and therapeutic care and seeks resources when appropriate.
  • Safely performs and accurately documents procedures, consistent with established nursing policy and procedure.
  • Patient Care Evaluation
  • Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team.
  • Evaluates progress toward nursing goals and revises goals as needed on a weekly basis.
  • Completes nursing progress note for assigned patients on a daily basis.
  • Completes nursing flow sheets for assigned patients on a daily basis.
  • Teaching
  • Evaluates education needs of patient and significant others and documents their response to teaching.
  • Utilizes, adapts, and revises teaching resources to meet patient education needs.
  • Explains procedures, tests, and disease process to patients and families as needed.
  • Acts as role model for health care students and other team members.
  • Acts as preceptor to assigned orientees.
  • Assists in the orientation of new staff by sharing knowledge and experience.
  • Patient Care Communication
  • Reports and documents accurately and concisely to appropriate persons the patient's condition.
  • Maintains patient confidentiality.
  • Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others.
  • Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed.
  • Gives and accepts constructive feedback appropriately.
  • Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives.

CORE COMPETENCIES

Standard I: Utilizes the Nursing Process

  • Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
  • Spiritual, and development needs of patient and families
  • Communicates findings to appropriate healthcare team members
  • Develops and uses a specific plan of care and modifies it to meet individual patient
  • needs using evidence-based practice. Implements patient care and therapeutic
  • procedures; monitors and documents progression of treatment and teaching goals
  • Evaluates the care and treatment(s) provided to the patient and the patient response to
  • the care and treatment(s). Performs timely reassessment and documentation
  • Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population

Standard II. Patient Throughput & Patient Flow Process

  • Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
  • Utilizes appropriate systems of communication and tools to facilitate the discharge process
  • Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy

Standard III. Unit Operations

  • Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
  • Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
  • Assesses departmental staffing needs; actively participates in resourcing efforts.
  • Educates and trains others on the operations, ethics, and regulations within the industry

Standard IV. Safe Practice/Quality Care/Regulations

  • Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
  • Demonstrates accountability for nursing research and quality improvement activities
  • Provides evidence-based nursing care
  • Communicates patient information effectively across the continuum of care
  • Educates and trains others on the operations, ethics, and regulations within the industry.
  • Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities

TECHNICAL COMPETENCIES

Clinical Policies and Standards

  • Follows a specific set of standards and associated clinical procedures
  • Analyzes policy and standards documentation and ensures organizational compliance
  • Provides feedback for improvement of procedures
  • Assists in the development and implementation of specific procedures
  • Works with control and monitoring mechanisms, tools and techniques

Health Information Documentation

  • Shares experiences with maintaining paper and electronic patient documentation
  • Walk through the steps and procedures for receiving, validating and updating patient records
  • Describes the flow of information between various stations or units
  • Discusses the functions, features and document flow of electronic documentation
  • Transcribes verbal orders; explains techniques for ensuring their accuracy
  • Explains health information documentation best practices and their rationale across health care practices

Medical Equipment

  • Describes experience with basic medical equipment used in own unit or facility
  • Uses standard diagnostic tools and techniques to resolves common equipment problems
  • Educates patients about the appropriate use of home medical equipment
  • Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
  • Inspects, troubleshoots and evaluates incoming equipment

Medical Order Processing

  • Shares experiences with processing medical orders for one or more groups of patients or conditions
  • Describes functions and features of the system used to enter, validate, update and forward medical orders
  • Discusses common errors, their sources and procedures for correcting
  • Explains considerations for entering and following standing orders
  • Differentiates between standing orders and preprinted orders and considerations for each
  • <.

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