Registered Nurse PT Days

Job Summary

Provides planning and delivery of direct and indirect patient care through the nursing process of Assessment, Planning, Intervention, and Evaluation. Develops nursing care plans in coordination with patient, family and interdisciplinary staff as necessary. Communicates changes in patient’s clinical condition with Physicians, Nursing Supervisor/Manager, and co-workers as appropriate. Participates in discharge planning process.

Maintains the standard of nursing care and implements policies and procedures of the hospital and nursing department

• Directs, supervises, provides and evaluates nursing care provided to patients
• Assigns or delegates tasks based on the needs and condition of the patient, potential for harm, complexity of the task, and within scope of practice of the staff to whom the task is delegated
• Sets up nursing care team members in accordance with patient needs, team member’s capabilities and qualifications

Documents patient admission assessment and reassessments, patient care plans and other pertinent information, completely in the patient’s medical record according to nursing standards and policies

• Makes assessments on all patients on admission and reassessments as per policy
• Develops nursing care plan of assigned patient on admission, updates plan of care as needed and ensures plan of care is coordinated with patient, family, and other members of the team
• Affirms the plan of care as indicated by the patient’s response to treatment and evaluates overall plan daily for effectiveness

Maintains patient care responsibilities considering needs specific to the standard of care for patient’s age

• Performs patient care responsibilities considering needs specific to the standard of care for patient’s age
• Receives physician’s orders, ensures transcription is accurate and documents completion
• Administers medication utilizing the five rights of medication administration reducing the potential for medication errors

Formulates a teaching plan based upon identified learning needs and evaluates effectiveness of learning; family is included in teaching as appropriate

• Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors
• Communicates appropriately and clearly to management, co-workers, and physicians
• Identifies and addresses psychosocial needs of patients and family; communicates with Social Service/Discharge Planner regarding both in hospital and post discharge needs

Qualifications

• Education: Graduation from an accredited Bachelor of Science in Nursing, Associate Degree in Nursing or Nursing Diploma program
• Licenses/Certification: Current state licensure as Registered Nurse, BCLS certification required, ACLS certifications preferred