This role demonstrates the use of the nursing process as a problem-solving model, utilizing knowledge and experience to anticipate and plan to meet patient and family needs at the time of admission, transfer, and discharge. The nurse reviews all orders on new admissions, transfers, and discharges, and communicates patient changes and conditions with assigned team members. They communicate with patients/families within 24 to 72 hours of admission and daily with the interdisciplinary team after rounds. Collaboration with the Primary RN, case managers/social services during the patient's stay is essential. The nurse assumes a proactive role in coordinating interdisciplinary discharge planning for a specific patient population and facilitates outpatient resources needed by the patient in collaboration with the interdisciplinary team. Working with NPs and other Providers throughout the stay ensures the patient is ready for discharge by 12 noon. The role demonstrates commitment to meeting the learning needs of patients and families, utilizing appropriate resources to achieve positive patient outcomes. The nurse assists patients/families to maximize their sense of control and actively participate in recovery. They support the patient discharge process, including medication reconciliation, finalizing discharge orders, completing the discharge summary, providing patient/family education, and documenting discharge teaching. Validation of patient/family education and comprehension prior to discharge is crucial. The nurse facilitates all follow-up appointments and ensures ordered tests/procedures are scheduled prior to discharge. Communication with patients/families 24 hours post-discharge and documentation of the encounter in UChart (telephone encounter) is required. Patient follow-up is conducted at 7, 14, and 30 days post-discharge and as needed, with documentation in UChart. The nurse serves as a liaison between the medical/surgical team for patients/families post-discharge. They demonstrate the knowledge and skills necessary to provide care appropriate to the age and needs of the patients served on the assigned unit. Serving as a direct care provider, as appropriate, ensures positive outcomes. Maintaining a safe and clean environment that promotes patient/family safety throughout all environments of care and complying with regulatory standards, including National Patient Safety Goals, are key responsibilities. The role also demonstrates creativity and innovation in approach to complex problem-solving.
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Job Type
Full-time
Career Level
Mid Level