Position Summary:The RN is responsible for patient-centered, total care of the patient on the floor, including basic nursing care and assessment and critical thinking skills to provide optimal patient care to prepare the patient for discharge. The RN will provide physical and psychological support to the patient, along with education for both the patient and their families.
Duties and Responsibilities:
Collects patient health data
Determines the priority of data collection based on the patient's immediate condition or needs
Collects pertinent data using appropriate assessment techniques
Involves the patient, significant others, and healthcare providers in data collection, when appropriate
Ensure that the data collection process is systematic and ongoing
Documents relevant data in the medical record according to hospital standards
Evidences the knowledge and ability to assess and interpret data about the patient's growth and development in order to identify each patients' needs and provide the appropriate care, including age-related care, where appropriate
Analyzes the assessment data in determining the patient's health problems.
Identifies expected outcomes individualized to the patient
Documents outcomes as measurable goals
Formulates outcomes mutually with the patient and healthcare providers when possible
Plans patient care to attain expected outcome
Indicates knowledge of the physiology, pathology, and psychology relevant to the patient's health problems
Relates observations to physiological, pathological, or psychological changes
Recognizes contributions of other health professionals and the need for referral to other departments
Facilitates patient and family participation
Individualizes the plan to the patient's condition or needs
Ensures the plan reflects current nursing practice
Documents the plan
Implements plan of care
Establishes interventions that are consistent with the plan of care
Carries out nursing care in a safe and appropriate manner which provides for the patient's:
Correct body posture
Psychosocial, physical, and spiritual needs
Performs treatments or nursing procedures in a non-judgmental and non-discriminatory manner which provides for:
Effectiveness of treatment
The patient's physical and psychological comfort
The protection of patient's dignity and rights
The maintenance of safety
Follows hospital policy and procedure for administering medications
Follows hospital policy and procedure for IV therapy
Documents all interventions
Assesses and reports changes in the patient's condition following the proper line of communication
Documents patient's response to interventions
Evaluates the effectiveness of interventions in relation to outcomes
Demonstrates knowledge of the use of equipment which is used on the nursing unit
Helps the patient and family to:
Understand his/her illness or treatment
Plans for care following discharge
Translates nursing decisions and physician's orders into action promptly, using judgment and demonstrating an awareness of cause and effect.
Explains tests and treatment in terms that the patient understands.
Gives verbal and or written reports which are pertinent, precise, and complete.
Initiates and maintains constructive relationship with co-workers.
Observes lines of communication appropriate to the circumstances.
Gives clear directions to others when delegating responsibility.
Documentation to reflect the care given and evaluated.
Demonstrates knowledge of current computer system used in the organization.
Sets priorities for patient care, and organizes own time and activities effectively for giving nursing care.
Demonstrates understanding of the needs of the total nursing unit on his/her shift.
Formulates recommendations to improve nursing care and patient outcomes.
Identifies need for change and initiates to enhance the quality of nursing care.
Shows awareness of the influence of his/her performance on co-workers.
Acquires and maintains current knowledge in nursing practice.
Contributes to the professional development of peers, colleagues, and others.
Assumes the role of patient advocate.
Decisions and actions on behalf of patient are determined in an ethical manner.
Willingly accepts assignments to special projects.
Utilizes supervision effectively.
Assists other staff when possible. Floats to other areas as assigned; responds to floating requests with a positive attitude.
Economical in the use of supplies and equipment.
Remains composed and directive during emergency and stressful situations.
Nurse to nurse report at the beginning and end of shift; Report significant events and patient care issues to on-coming nurse.
Assign floor personnel to patient care, taking into consideration patient acuity levels. Post floor assignment.
Receive notification of new admission from ED, Physician office or House Supervisor. Provide pertinent information to assist in the appropriate bed assignment. Review Physician orders, clarify orders as necessary.
Initiate transfer form on patient as necessary (home health, nursing home, other facility).
Participate and facilitate participation by appropriate team members in Patient Care Conferences and Interdisciplinary Team Meetings.
Communicate or facilitate communication, and information on patients condition/change in condition and pertinent diagnostic results (to include all Critical Values) to Physician
Keep the Med-Surg/ICU Director informed of all patient and personnel issues. Reports to the House Supervisor in the Director's absence.
Ensure completion of incident reports on all untoward events occurring in the unit, including near-misses.
Assists with ordering supplies according to pre-determined par levels on Monday, Wednesday and Friday.
Assign or complete daily and monthly QI tasks to personnel ie: refrigerator temperature checks, crash cart checks, supply outdates, stocking supplies, etc.
Assist Director with PI/QI data collection and make recommendation for improvements.
Effectively deal with noise and disruptions at the Nurse's Station.
Responsible for direct observation of Performance Improvement initiatives and observation of the National Patient Safety Goals by all staff members.
Assist in formulating Performance Improvement Plans and re-evaluations as needed.
Any other duties as assigned by the Med-Surg/ICU Director.
Complies with federal, state, and local legal requirements by studying existing and new legislation; anticipating legislation; enforcing adherence to requirements; advising management on needed actions; ensures compliance with Joint Commission and other external and internal regulatory agencies.
Maintains the integrity of confidential patient information in accordance with HIPAA and hospital policy, including accessing, using and disclosing patient information relevant to the individual employee's job duties. Also maintains confidentiality of other customer and hospital business affairs.
Adheres to the standards of Magruder Hospital's corporate compliance policies and seeks guidance and training when necessary to resolve questions about the policies. Reports violations in accordance with corporate compliance and organizational standards.
Attendance is an essential function of this position. Reports to work on time and as scheduled; Shows respect for co-workers by following established break times; Keeps personal conversations and telephone calls to a minimum.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Other duties as requested or assigned.
Education and Experience:
Associate Degree from an accredited school of nursing.
Organizational/time management skills
Bachelor's Degree from an accredited school of nursing.
Basic EKG rhythm interpretation
Prior charge nurse experience
Certifications & Licenses:
Current RN license by the State of Ohio
Current BLS* Certification
*BLS certification is required upon hire.ACLS certifications are required to be achieved as soon as possible but not later than one (1) year after hire date. All certifications required in this job description must be maintained by the employee throughout their employment
ACLS Certification and proficiency in telemetry monitoring