Job Description
Job Description
JOB SUMMARY :
Under the guidance of the Nurse Manager the Staff RN is responsible for the provision of patient assessment , plan-of-care, implementation of plan and evaluation of patient care utilizing the nursing process to ensure quality of patient care.
The Staff RN is responsible for carrying out duties as assigned and delivers care to patients in accordance with NHSC policy.
The Staff RN constructs and updates a Nursing plan of care in conjunction with the medical plan of care that reflects comprehensive assessment of the patient and documents all Nurse patient interaction utilizing the "SOAP" format.
Utilizing a case management approach to care, the Staff RN evaluates the effectiveness of nursing care and updates the nursing plan as indicated.
The Staff RN also participates in quality assurance activities as directed and administers medications / treatments / immunizations prescribed by the physician in accordance with policy and procedure.
The Staff RN is responsible for continuing education.
ESSENTIAL FUNCTIONS and PRINCIPAL ACCOUNTABILITIES :
Uses the nursing process and guidelines to correctly complete and document relevant patient assessment on site.
Promotes the family centered approach to patient care.
Documents assessment via computer / chart.
Applies knowledge of growth and development over the life span.
Ensures appropriate referrals and follow-up.
Provides telephone / walk-ins triage in accordance with NHSC guidelines and policy.
Assesses need for patient / family education.
Utilizes the Child & Geriatric Abuse Policy in the Assessment process .
Plans the nursing intervention of patients, demonstrates an understanding of the impact on family and community along with interdisciplinary team.
Documents plans, goals, and patient outcomes.
Utilizes available resources in planning of care.
Participates in the establishment of department goals in the education of patients and their families.
Evaluates and updates plan of care.
Executes physician orders in accordance with nursing standards, NHSC policies and procedures and documents appropriately immunizations.
Administers ordered medications in accordance with NHSC policy and procedure.
Communicates appropriately with patient, families, peers and staff.
Negotiates the plan of care with patient and family.
Implements physician "standing order(s)".
Synthesizes relevant findings in the application of the Nursing process and intervenes appropriately.
Understands and demonstrates Universal Precaution measures in all patient care activities
Maintains necessary flowcharts on appropriate forms 22.Documents care implemented
Provides patient / family education in compliance physician order or assessed need.
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