Under general supervision, is responsible for the clinical management of patients in accordance with hospital, State and National regulatory agency standards. Assumes responsibility for the initial evaluation and treatment of admitted surgical patients, except for emergency admissions. Performs admission history and physical as evidenced by appropriate documentation. Writes appropriate orders within approved delegation agreements. Discusses with the attending physician and nursing staff, physical and/or emotional findings which impact patient care. Evaluates patient progress on a continuing basis and, in collaboration with the attending physician, alters treatment modalities. Make daily rounds on assigned patients to evaluate medical, social and educational needs. Initiates referral to appropriate ancillary departments and community resources based on patient need and documents on the progress note. Writes progress notes daily, documenting pertinent information regarding patient progress and treatment regime. Writes orders appropriate to the patient's care requirements in compliance with hospital policy. Establishes medical diagnoses in compliance with standard accepted medical practice. Refers to the attending physician or designee those problems, which require consultation and documents it on progress note. Makes immediate referral of acute and/or life threatening patient conditions to attending physician or designee. Documents physical findings and treatment plan pertaining to same. Performs technical functions as covered by the job description and delegation agreement submitted to BPQA and/or MBON, approved NP agreement and in accordance with hospital policy. Documents results of technical functions performed. Reports to physician or designee any abnormal findings related to it. Monitors patient response related to technical function performed and document it. Acts as a clinical resource. Actively supports and participates in nursing and/or hospital performance improvement initiatives. Performs activities to meet patient/family education needs. Participates actively in health teaching of patient and family to include preventative health care, as well as current medical condition and treatment regime. Plans and reviews home care instructions with patient and family if needed. Includes needs for service provided by community resources and hospital based ancillary services. Maintains continual communication with health team members regarding patient education and discharge planning. Assumes responsibility for utilizing opportunities for educational advancement by pursuing activities to meet identified educational needs and those required for continued certification as well as attending mandatory inservice as required.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree