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RN, Registered Nurse - IMC MedSurgical A

CHRISTUS Health
San Marcos, Texas
Full-time

Details

Salary : Open

Categories : General Nursing

General Nursing

Internal Number : Description

Description

Summary :

The competent Nurse, in the same or similar clinical setting, practices independently and demonstrates an awareness of all relevant aspects of a situation.

Provides routine and complex care, with the ability to on long-range goals or plans. Continues to develop the ability to cope with and manage contingencies of clinical nursing.

Makes appropriate assignments and delegates to other care providers as a means to help manage the clinical situation.

Responsibilities :

  • Meets expectations of the applicable OneCHRISTUS Competencies : Leader of Self, Leader of Others, or Leader of Leaders.
  • Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients.
  • Addresses increasingly complex psychological, emotional, cultural, and social needs of patient and families in accordance with their level of practice.
  • Using the appropriate protocol, administers medications and treatments; monitors for side-effects and effectiveness of the treatment prescribed.
  • Documents patient history, symptoms, medication, and care given.
  • Assess learning needs and provides education to patients, family members and / or care givers; identify issues and resources.

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 the 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

Patient Chart Reading and Interpretation

  • Describes experiences in reading and interpreting patient charts for patients on unit and under own care
  • Reviews patients' charts for completion and accuracy; identifies and alerts to mistakes or omissions
  • Recognizes unexpected readings and alerts nursing or medical staff
  • Relates examples of mis-readings or misinterpretations and lessons learned
  • Reviews, discusses and validates own interpretation with others

Patient Safety

  • Shares experiences with ensuring safety for one or more patient groups or settings
  • Explains key features of safety guidelines and procedures for those groups and settings
  • Listens and responds to safety inquiries from patients and family members
  • Recognizes and addresses physiological and psychological signs of problems
  • Describes considerations for patients who can cause to harm to self, versus harm to others
  • Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real-time

Requirements : Education / Skills

Education / Skills

Bachelor of Science Degree in Nursing, preferred

Experience

1 year of experience in the related nursing specialty preferred

Licenses, Registrations, or Certifications

  • BLS required
  • 30+ days ago
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