1. Assesses the physical, psychological, and social dimensions and the educational needs of the patient on admission and completes a written assessment within the time frame designated by the type of patient.
2. Identifies patient needs and formulates a written care plan based on the assessment of the patient. Care plan is initiated within 24 hours of admission.
3. Plan of care is implemented and documentation of effectiveness is reflected in the medical record. Revises/updates the plan as necessary, at least every 24 hours.
4. Utilizes leadership skills through delegation to, communication with, and evaluation of team members.
5. Recognizes changes in status of the patient and provides appropriate intervention and documentation.
6. Prioritizes care based on individual needs.
7. Initiates appropriate referrals as identified to meet the discharge needs of patients in collaboration with case management.
8. Assists in assuring correct sponge, needle, and instrument counts.
9. Applies principles of aseptic and infection control technique as either a scrub or circulating nurse.
10. Provides ongoing patient and family education based on daily assessment of disease process, care requirements, and expected recovery.
11. Participates in inservice and/or continuing education to maintain and improve understanding of the present and future trends in health care, and participates in unit and hospital wide committees to identify needs and assist in continuous performance improvement.
12. Communicates identified unit problems following appropriate chain of command (charge nurse, director/supervisor, vice president), and actively participates in the problem solving process.
13. Documentation of patient care is done through Perinatal Database (OBIX), Meditech, and Bedside Medication Verification.
14. Demonstrates job related aspects of patient safety to assure a safe environment, safe and effective use of equipment and technology, and decreased risk of potential adverse patient occurrences.
15. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.
16. Demonstrates the knowledge and skills necessary to provide care appropriate to the age of patients served on his/her assigned unit. Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs, and to provide the care needed as described in the unit's and division's policies and procedures.