DUTIES AND RESPONSIBILITIES 

I.                    RESPONSIBILITIES TO THE PATIENT

A.     Initiates an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient/family through interview, observation, and physical examination.

1.      Receives admissions and/or transfers to the unit.

2.      Completes nursing database within 24 hours.

B.     Interprets assessment data and information to develop a nursing care plan which contains problem identification, nursing diagnosis, nursing orders, approaches, interventions, short/long term goals, and discharge planning.

1.      Develops nursing care plan utilizing nursing diagnosis

2.      Assesses safety and fall risk levels for patients

C.    Teaches and counsels patients/families, and makes referrals to appropriate resource personnel when needed.     

1.    Demonstrates documentation for functional training visit.     

2.    Documents patient, family, and significant other teaching

D.   Participates as a productive member of the interdisciplinary team in assessment, planning, implementation and evaluation of rehabilitation goals.

E.  Assures that medical orders are transcribed and processed accurately,          and integrates the medical care plan into the provision of nursing care.

F.  Assures that medication/I.V. administration is correct and according to the established nursing policies and procedures.     

1.   Looks up unfamiliar medications

2.   Processes medication orders.

3.      Administers medications as ordered

4.      Evaluates effectiveness of PRN medications

5.      Verbalizes process for self-administered medications

6.      Verbalizes patient education on identified medications

7.      Verbalizes standing orders

8.      Verbalizes policy and procedure for maintenance and care of central line catheters.

9.      Identifies critical drip medications; able to locate critical drip policies and administers according to policies after completing critical drip competency training

10. Regulates drip rates as ordered.

11. Administers I.V. drugs

G.     Provides for personal and environmental safety in accordance with hospital and nursing policies and procedures.

H.      Demonstrates skills in handling emergency and life-threatening situations.     

1.    Locates and uses crash cart items.     

2.    Calls Code Blue and Medical Emergency     

3.    Initiates CPR     

4.    Follows P&P and DNR 

I.    Assures that documents in the medical record are complete, factual,  accurate and timely.

1.      Documents materials and equipment used.

2.      Verbalizes method to noting orders.

3.      Documents discharge in chart.

4.      Initiates and updates care plan as appropriate.

5.      Provides discharge instructions.

6.      Completes interagency transfer form.

J.      Provides nursing care to meet patient needs:

1.      Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools.

2.      Acts promptly on changes in patient condition, utilizing SBAR method

3.      Reviews lab and test results, notifying physician of abnormal and critical results

4.      Performs wound care in accordance with policy, utilizing proper documentation tools.

5.      Performs basic ventilator management and trouble-shooting. 

II.                  RESPONSIBILITIES TO UNIT STAFF

A.     Provides direction and leadership in patient care to assigned personnel.

1.      Acts as a team leader.

2.      Makes assignments for team.

B.     Prioritizes activities and plans for effective use of time and staff in meeting patient needs.

C.    Communicates the plan of nursing care for each patient through reports, conferences, rounds, and patient care records.     

1.    Shift to shift report and shift huddle with LPNs and aides     

2.   Delegates tasks to LPNs and aides; monitors to make sure delegated tasks are completed appropriately.

D.  Demonstrates responsibility for the teaching of staff in areas of new techniques, policies and procedures.     

1.   Preceptor

E.  Participates in the quality improvement activities of nursing.     

1.   Attends appropriate meetings.

F.  Communicates identified learning needs of self and others to the DCS.

G.  Assists the DCS in the orientation of new staff.H.  Adheres to established policies and procedures of the hospital and     Nursing Department.

I.    Actively participates on nursing committees.

J.   Performs other duties as assigned or requested. 

III.        RESPONSIBILITIES TO SELF

A.     Evaluates own performance and seeks opportunities for growth and       expansion of skills

B.     Takes initiative in upgrading and maintaining skills necessary to provide       quality care to provide quality care to patients and leadership to assigned staff.

C.  Acquires continuing education sufficient to maintain licensure and certification     

1.   Maintains current nursing licensure     

2.   Provides Human Resources and DCS with a copy of current nursing license.     

3.   Maintains required competencies as defined by SERC     

4.   Completes assigned program tracks on Genesys as assigned by DCS     

5.   Completes appropriate level of Clinical Advancement within established timeframes

D.  Membership in appropriate professional organizations.

E.  Assumes responsibility for maintaining/enhancing physical health and alleviating stress     

1.   Attendance

F.   Demonstrates competency in a variety of nursing skills as demonstrated and evaluated on at lease an annual basis.     

1.   Attends annual skills fair

G.  Displays a “customer service” attitude toward patients, visitors, and other staff members at all times.     

1.   Demonstrates basic telephone skills (how to answer, place on hold, and transfer a call.)     

2.   Utilizes intercom     

3.   Demonstrates how to page physicians or others on call.

H.  Abides by all safety, infection control, and other guidelines as required.     

1.   Follows guidelines for caring for patients in isolation     

2.   Utilizes hand-washing techniques     

3.   Cleans equipment between patient usage.     

4.   Reports personal symptoms of suspected illness or contagious disease to the Employee Health Nurse.     

5.   Demonstrated knowledge of universal blood and body fluid precautionsI. 

I.    Promotes an ethic of continuous quality improvement in all matters associated with the position, and documents specific quality improvement implementation.

J.      Performs all other tasks and duties as may be assigned.

K.     Provides a level of competency to treat patients 13 to 100 plus years of age.     

1.  School age:                 

a.  Explains procedure to a child at his/her level of understanding                 

b.  Includes parents in teaching.                 

c.  Allows child to have some control while allowing for mobility and functional needs.     

2.       Adolescents (16 years and up):                 

a.  Explains procedures in terminology they can understand.                 

b.  Encourages their input in planning goals.                 

c.  Alleviates any fears by addressing all questions.                 

d.  Provides privacy and space of their own while establishing ground rules.     

3.       Adults:                 

a.  Involves them with care planning by meeting any needs they identify during assessment                 

 b.  Identifies their normal patterns of living and strives to attain them     

4.       Geriatric:                 

a.  Strives to obtain understanding by speaking distinctly and moving slowly.                 

b.  Involves family as much as possible 

IV.               DRESSES AND PRESENTS SELF IN A PROFESSIONAL MANNER AT ALL TIMES.  ADHERENCE TO THE CORPORATE APPEARANCE POLICY IS REQUIRED. 

V.       WEARS HOSPITAL ISSUED NAMETAG AT ALL TIMES WHILE ON DUTY 

VI.               CONDUCTS SELF ETHICALLY AT ALL TIMES. 

VII.      UPHOLDS ALL SERVICE STANDARDS

A.     Safety- We do no harm and create an error-free environment.

1.      Follow environment of care plan

2.      Follow established clinical practices

3.      Routine assessment of the environment for high risks with immediate correction (look for dangerous things and fix them; identify high risk issues and fix them)

4.      Pay attention to detail 

B.     Communication- We engage our customers in exchanging clear, timely and accurate information.

1.      Listen carefully

2.      Ensure understanding of treatment and services

3.      Timely follow-up on commitments

4.      Constantly learn about the customers and identify their needs 

C.    Courtesy- We treat everyone with respect, social sensitivity and professionalism.

1.      We acknowledge our customers with a smile and treat them as welcomed guests

2.      Listen to our customers

3.      Look at each interaction as an opportunity to promote courtesy with our customers

4.      We treat each other as we treat our guests

5.      We strive to exceed our customers expectations 

D.    Presentation- We provide a positive customer experience through the appearance of our environment and employees.

1.      Maintain a clean and organized environment, including workspaces

2.      Control hospital odors

3.      All employees are compliant with the dress code

4.      All employees communicate in a professional and courteous manner, including body language

5.      Protect the privacy of patients

6.      Maintain a quiet atmosphere 

E.     Efficiency- We use resources appropriately to benefit the customer and the organization.

1.      Availability, assessment and application of resources

2.      Do it right the first time

3.      Pay attention to details

4.      Save steps through planning

5.      Timely responses