Registered Nurse RN Medical Unit

Core Functions

• Affirms patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs.
• Reviews patient history and physical with patient/family and assures completion within appropriate timeframe.
• Reviews available information obtained by other health care team members.
• Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers.
• Completes assessment and reassessments according to patient need and as outlined in policy.
• Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input.
• Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care. Goals for patient are realistic, measurable and developed in conjunction with the patient/family.
• Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patient’s status.
• Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team.
• Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
• Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed.
• Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members.
• Evaluates patient's response and the effectiveness of patient teaching.
• Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy.
• Notes physician orders accurately and in a timely manner.
• Provides care based on the best evidence available and may participate in research activities within clinical practice.
• Participates in unit or facility shared leadership.
• Interacts and participates in the education, role development, and orientation of facility personnel, patients, students, families and visitors.
• Promotes/supports growth of others through precepting and mentoring when appropriate.
• Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care.
• Actively participates in the improvement of national nursing quality indicators and outcomes. Such activities may include participating in professional organizations.

Qualifications

• Current, valid RN license in state of practice, temporary/interim RN license in state of practice, or compact RN licensure for current state of practice.
• BLS certification is required.
• Additional certification or continuing education may be required based on area of practice.
• Minimum of one year experience in an acute care hospital setting preferred.
• Experience in the clinical area for which he or she is applying is desired.
• Maintains clinical performance competencies appropriate to the area in which they work as demonstrated through annual validations.