Directs work to improve department performance and customer satisfaction.
1. Will be achieved if department has reached its established customer satisfaction goal.
Performs and documents appropriate relevant assessments and initiates appropriate protocols/plans.
1. Evaluates self-care abilities/limitations and identifies need for additional safety measures, e.g., high risk for falls, wounds and skin protocol, referrals to HHC, Diabetic P.T., (etc.)
2. Admission assessment thoroughly completed in a timely period.
3. Shift assessments every twenty-four and prn as relevant condition warrants.
4. Evaluates and documents signs/symptoms of abuse or neglect. Follows appropriate evaluation and reporting procedures.
Develop a plan of care reflecting interventions and goals that are essential to the patient's immediate health care needs., e.g., pain, need for rehab, P.T., ambulation, dietary.
1. Initiates plan of care upon completion of admission.
2. Documents evidence of patient/family input into plan of care that reflects age and level of understanding.
3. Documents evidence of discharge planning to begin at admission, e.g., C.C., S.W., HHC, physician/family input.
4. Documents appropriate clinical documentation reflects linking goals, interventions, and relevant patient/family teaching with response.
5. Follows procedures for obtaining consent to treat, respectful of patient's rights.
Makes effective nursing decisions on delivery of patient care based on clinical expertise. Delegates appropriately to healthcare team members.
1. Implements physician orders accurately in a timely manner.
2. Utilizes critical clinical decision making skills by reporting and acting upon changes in patient condition.
3. Documents evidence of utilizing collaborative pathway, specific teaching tools and discharge instructions for patient population.
4. Coordinates and communicates with team members to assure that the plan of care is properly implemented and patient needs are met.
5. Monitors vital signs and is aware of accepted normal ranges for age group.
6. Prepares and administers medication doses based on weight and age.
7. Follows Nursing Policies & Procedures for specific interventions such as, Pain Management, blood transfusion, etc.
Evaluates and documents patient's response to the plan of care.
1. Completes educational needs assessment upon admission.
2. Modifies plan of care and teaching as needed based on clinical, age-related, behavior, motor skills and cognitive and physiological norms.
3. Recognizes patient's level of psychosocial and psychosexual development and modifies plan of care accordingly.
4. Documents pertinent changes in clinical conditions, notification of physicians and orders received.
5. Documents evidence that information regarding the medical/nursing plan of care has been communicated to patient/family/S.O., e.g., tests, procedures, med D's, lab work, lifestyle changes.
This is PRN position (as needed)
Must work 32 hours a month with one shift being a weekend shift
Must be flexible to work in different departments and different shifts