• Develops and evaluates plan of care. o Systematically and continuously assesses patient's knowledge base and physical, psychosocial and spiritual health through interviews, physical examinations and data collection o Consults with multidisciplinary health care team in regard to nursing assessment findings. o Creates written, individualized plan of care based on priority of patient problems, anticipated length of stay, input from patient and family and other members of the health care team. o Communicates pertinent information and changes in patient status to appropriate members of care team and other health care providers, as necessary. o Collaborates with team members to make changes in plan of care, as necessary. • Provides and/or delegates patient care according to the plan of care and established protocols. o Utilizes clinical resources in implementing patient care and provides rationale for patient care decisions. o Conducts clinical rounds, provides emergency care and administers medications to patient. o Operates equipment required for patient care according to manufacturer's recommendations. o Performs and assists with procedures and treatments on unit including but not limited to changing dressings, feeding patients and providing pre/post operative care. o Practices and monitors infection control standards. o Promotes and provides patient safety in accordance with state and federal guidelines. • Documents patient care, as required on all appropriate forms. o Enters date and time of entry and signs name in legible manner on patient's chart. o Completes Nursing Admission Assessment 24 hours after admission. o Documents patient's response to interventions and plan of care on the Progress Notes o Performs vital signs and pain score at least every four hours. o Completes Transfer Assessments on patients transferred out of the unit and Perioperative Assessments on patients scheduled for surgery or procedures. o Completes Frequent Observations and the Intake/Outtake Record according to established protocols. o Initiates and completes health care referrals in collaboration with the interdisciplinary team. • Provides patient education. o Identifies patients learning needs upon admission. Informs and educates patient and family to enable participation in their care and decision making. o Develops and implements a teaching plan of care. Conducts patient teaching conferences. Documents patient teaching. • Participates in Quality Improvement process. o Participates in developing and implementing of unit goals and objectives. o Attends in-service programs on new products and equipment used on unit. o Completes occurrence reports according to policy and unit-based audits, as assigned. o Participates in identifying problems requiring investigation and in developing and implementing corrective action plans for the unit. • Participates in unit staff meetings and unit based clinical conferences, as scheduled. Represents the clinical unit on committees, as assigned. Submits annual record of continuing educations and self-assessment of clinical performance. • Performs the responsibilities of charge nurse and preceptor according to established protocols, as assigned. • Performs related duties, as required. ADA Essential Functions
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees