Registered Nurse

What You Will Do

• Provides nursing care according to medical regimen and the nursing interventions appropriate for the patients' conditions and according to established standards, policies and procedures including care of the ambulatory practice patient.
• Initiates assessment based on the patient's presenting problems or needs, the physician's medical diagnosis and the functional health framework upon visit.
• Collections key information from patient, family, laboratory, and other medical reports.
• Determines nursing diagnosis and priorities for care with special consideration given to patient teaching, discharge planning, and the growth and development needs of the patient.
• Determines which standards of care and practice apply to the patient.
• Documents assessment, including nursing diagnoses or other clinical judgments.
• Completes ongoing assessments according to outpatient and nursing policy and/or as determined by patient condition:
• Re-prioritizes care based on new information,
• Continues to update nursing diagnoses, and
• Involves family and/or other significant individuals in assessment activities.
• Affirms care of assigned patients.
• Performs therapeutic nursing interventions as ordered by the Physician
• Consistent with primary and population-specific standards of care and practice
• With consideration given to knowledge gained from the initial and ongoing assessment of the patient
• Consistent with nursing division policies and procedures, demonstrated competencies, and with consideration given to risk management, infection control practices and patient safety practices
• Consistent with the nature of the unit:
• Completion of history and physical assessment
• Administration of medication, treatments and immunizations
• Prepares patient for examination/procedures; positions and drapes patients
• Pain control interventions
• Provides assistance during examination/procedures
• Makes patient responses during treatment/procedure (checks temperature, pulse, blood pressure and respiration)
• Initiates corrective action whenever information from monitoring or life support equipment shows adverse symptomatology such as respiratory or cardiac insufficiency
• Coordinates patient referrals
• Patient education
• Documents care based on standards of care and practice and/or clinical priorities for documentation including:
• Assessment and ongoing assessment findings
• Updated clinical priorities for documentation
• Patient's response to interventions and progress towards outcomes are noted
• Responds and/or participates with medical emergencies. Initiates and/or assists with CPR/BLS as required.
• Provides teaching to patient/family in the care of disease/condition. Develops and implements patient teaching outlines including objectives, content, teaching strategies and evaluation of patient progress.
• Maintains patient medical records; documents patient status and care given; performs charting duties; records activities and observations. Utilizes patient computer systems to enter and retrieve data.
• Confers and works collaboratively with patient/family/hospital staff regarding all aspects of patient needs in a customer responsive and courteous manner, in compliance with iRESPECT Standards and promoting patient/customer satisfaction.
• Provides instruction, assigns and supervises LPN and other support personnel assigned to unit to complete the initial and ongoing assessments of patients and to provide clinical assistance as needed. Assists in the orientation and oversee the supervision of new staff members and students when they provide patient care, treatment, and services as part of their training.
• Transports monitored patients, specimens, equipment and supplies to and from various areas.
• Collaborates with forensic team and security to provide safe environment for patients in custody.
• Completes required continuous training and education, including department specific requirements.
• Attends staff meetings, all mandatory in-services, and additional continuing education as required.
• Contributes to the annual review of unit-based scope statement and determination of important aspects of care for clinical review.
• Assists in the development of indicators, thresholds, study methods, and data collection as assigned.
• Responds to problems/opportunities to improve care.
• Supports and is involved in the organization’s performance improvement initiatives.
• Participates in and maintains competencies required for the position.
• Maintains a clean, orderly, safe environment for patients and personnel. Adheres to established policies, compliance/quality improvement, and safety, environment and infection control standards.
• Prepares and maintains required records, reports and files for administrative and compliance purposes.