SUMMARY: Plan, organize, direct, provide and evaluate care needed to maintain safety and improve the health and well being of patients through the implementation of the nursing process. Provides oversight for all nursing care processes provided by other members of the nursing staff. Serve as patient advocate and be actively involved in the care of the patient and support of family members. Communicate effectively for continuity of care among patients, families, ancillary personnel and hospital departments.
QUALIFICATIONS:
- Competent in medical terminology.
- Knowledgeable about the interventions and evaluations of drug therapy.
- Maintain discretion and confidentiality in communications.
- Knowledgeable about policies and procedures regarding reporting and release of protected health information (PHI).
- Competent in clinical skills and use of medical equipment.
- Knowledgeable of Infection Control and Prevention Programs.
- Knowledge of licensing requirements, nursing practice act, statutes and rules applicable to nursing.
- Maintain certifications and continuing education requirements needed to perform job.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Completes comprehensive assessment of inpatients upon admission and change in condition.
- Completes a focused assessment of patients each shift.
- Assures the completion of focused assessment throughout shift by Licensed Vocational Nurses and graduate nurses.
- Makes patient assignments in accordance with identified patient needs and documented competencies of nursing personnel.
- Establish, implement, evaluate and document patient plan of care and services.
- Provide education to staff, patient and family members promoting improvements in health care delivery.
- Administers transfusions of blood and blood products and patient medication administration as needed.
- Advocate for patient.
- Triage, assess and record patient’s history, signs and symptoms.
- Evaluate and report patient status according to standardized format.
- Perform point of care diagnostic tests, such as, EKG and glucometer readings.
- Continually monitor to assure medical provider’s orders for the patient’s care are being carried out.
- Inform medical provider of any changes in patient status.
- Provides oversight of nursing personnel (and EMS personnel, if relevant) and all clinical care provided.
- Interact with patients, family members, medical providers and ancillary personnel on a continuous basis.
- Carry out procedures for admitting, transferring or discharging patients.
- Knows and complies with practice standards of the state board of nursing.
- Miscellaneous duties as assigned requested or required.
