Registered Nurse I-Surg General-Full Time

Description

Summary :

Responsible for patient assessment, patient care planning,and provision of quality nursing care to an assigned group ofpatients for a defined work period.

Provides direction andsupervision to LVN / LPNs, nursing assistants, unit secretaries, andother clinical / clerical associates.

By assignment, may function asa charge nurse for the unit. Involves provision of patientcare / service to older adolescents, young adults, adults, geriatricand pediatric patients.

Responsibilities :

• Meets expectations of the applicableOneCHRISTUS Competencies : Leader of Self, Leader of Others, orLeader of Leaders.
• Patient CarePlanning
• Develops a comprehensive nursing careplan which addresses all significant needs and problems identifiedthrough nursing assessment.
• Prepares nursingelements of the interdisciplinary care plan prior to the initialteam conference.
• Reviews and updates nursingcare plan and collaborates with team members as changesoccur.
• Patient CareProvision
• Implements patient care as planned innursing care plan and interdisciplinary careplan.
• Sets priorities based on knowledge ofpatient acuity and patient needs.
• Providessafe and therapeutic care and seeks resources whenappropriate.
• Safely performs and accuratelydocuments procedures, consistent with established nursing policyand procedure.
• Patient CareEvaluation
• Evaluates patient response tointerventions and attainment of goals in collaboration withinterdisciplinary team.
• Evaluates progresstoward nursing goals and revises goals as needed on a weeklybasis.
• Completes nursing progress note forassigned patients on a daily basis.
• Completesnursing flow sheets for assigned patients on a dailybasis.
• Teaching
• Evaluateseducation needs of patient and significant others and documentstheir response to teaching.
• Utilizes, adapts,and revises teaching resources to meet patient educationneeds.
• Explains procedures, tests, and diseaseprocess to patients and families as needed.
• Acts as role model for health care students and other teammembers.
• Acts as preceptor to assignedorientees.
• Assists in the orientation of newstaff by sharing knowledge and experience.
• Patient Care Communication
• Reports and documents accurately andconcisely to appropriate persons the patient'scondition.
• Maintains patientconfidentiality.
• Applies basic verbal andnonverbal skills to maintain open, effective communication amongcare team members, patients, and significantothers.
• Encourages direct discussion betweenstaff members when differences occur and seeks assistance toarbitrate differences as needed.
• Gives andaccepts constructive feedback appropriately.
• Identifies actual and potentially unsafe patient care practices,reports them in the designated manner, and suggestsalternatives.

CORECOMPETENCIES

Standard I : Utilizes the NursingProcess

• Uses criticalthinking skills to assess the basic physical, psychosocial, social,cultural,
• Spiritual, and development needs ofpatient and families
• Communicates findings toappropriate healthcare team members
• Developsand uses a specific plan of care and modifies it to meet individualpatient needs using evidence-based practice.

Implements patientcare and therapeutic procedures, monitors and documents progressionof treatment and teaching goals

• Evaluates thecare and treatment(s) provided to the patient and the patientresponse to the care and treatment(s). Performs timely reassessmentand documentation
• Must be able to perform unitspecific competencies based on the specific patient care need fordesignated unit's patient population

Standard II. Patient Throughput & Patient FlowProcess

• Anticipates and plans foradmission / discharge / transfer needs to facilitate patientflow
• Utilizes appropriate systems ofcommunication and tools to facilitate the dischargeprocess
• Coaches on tools and techniques forchecking, cross checking and validating orders to ensureaccuracy

Standard III. UnitOperations

• Plans, directs, andevaluates the overall nursing care and functions in a particularnursing unit during an assignedshift
• Demonstrates good stewardship in properuse and maintenance of equipment andSupplies
• Assesses departmental staffing needs;actively participates in resourcing efforts.
• Educates and trains others on the operations, ethics, andregulations within the industry

Standard IV. Safe Practice / QualityCare / Regulations

• Incorporates patientsafety practices / guidelines to promote a safe environment resultingin positive patient outcomes
• Demonstratesaccountability for nursing research and quality improvementactivities
• Provides evidence-based nursingcare
• Communicates patient informationeffectively across the continuum ofcare
• Educates and trains others on theoperations, ethics, and regulations within theindustry.
• Knowledge of federal, state andlocal healthcare related laws and regulations; ability to complywith these in healthcare practices andactivities

TECHNICALCOMPETENCIES

Clinical Policies andStandards

• Follows aspecific set of standards and associated clinicalprocedures
• Analyzes policy and standardsdocumentation and ensures organizationalcompliance
• Provides feedback for improvement ofprocedures
• Assists in the development andimplementation of specific procedures
• Workswith control and monitoring mechanisms, tools andtechniques

Health InformationDocumentation

• Shares experiences withmaintaining paper and electronic patientdocumentation
• Walk through the steps andprocedures for receiving, validating and updating patientrecords
• Describes the flow of informationbetween various stations or units
• Discusses thefunctions, features and document flow of electronicdocumentation
• Transcribes verbal orders;explains techniques for ensuring theiraccuracy
• Explains health informationdocumentation best practices and their rationale across health carepractices

Medical Equipment

• Describes experience with basicmedical equipment used in own unit orfacility
• Uses standard diagnostic tools andtechniques to resolves common equipmentproblems
• Educates patients about theappropriate use of home medicalequipment
• Ensures that all equipment andrelated supplies are in proper working order prior to use to ensurepatient safety
• Inspects, troubleshoots andevaluates incoming equipment

MedicalOrder Processing

• Shares experienceswith processing medical orders for one or more groups of patientsor conditions
• Describes functions and featuresof the system used to enter, validate, update and forward medicalorders
• Discusses common errors, their sourcesand procedures for correcting
• Explainsconsiderations for entering and following standingorders
• Differentiates between standing ordersand preprinted orders and considerations foreach

Patient Chart Reading andInterpretation

• Describes experiencesin reading and interpreting patient charts for patients on unit andunder own care
• Reviews patients’ charts forcompletion and accuracy; identifies and alerts to mistakes oromissions
• Recognizes unexpected readings andalerts nursing or medical staff
• Relatesexamples of mis-readings or misinterpretations and lessonslearned
• Reviews, discusses and validates owninterpretation with others

PatientSafety

• Shares experiences withensuring safety for one or more patient groups orsettings
• Explains key features of safetyguidelines and procedures for those groups andsettings
• Listens and responds to safetyinquiries from patients and familymembers
• Recognizes and addresses physiologicaland psychological signs of problems
• Describesconsiderations for patients who can cause to harm to self, versusharm to others
• Utilizes appropriate systems todocument misses and near misses, participates in immediateinvestigating, analysis and reporting in realtime

Requirements :

• Bachelor of Science Degree in Nursing,preferred.
• Six months to a year of experienceas a licensed RN or holder of an active GNpermit.
• BLS required
• RNLicense in state of employment orcompact
• Graduate NursePermit
• Associates with an unsuccessfullicensure application or on the 75th day following the effectivedate of the temporary permit;

will be transferred to anotherposition within CHRISTUS Health

Work Schedule : Work Type :

Work Type : Full Time

Full Time

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