Registered Nurse

Department: Primary Care Whitman

Schedule: Full Time

ESSENTIAL RESPONSIBILITIES / DUTIES: 

1.0 Consistently and effectively utilizes all steps of the nursing process in the provision of timely, safe, efficient and appropriate patient/centered care. 

1.1 Assesses the patient and family in a systematic and ongoing manner for both overt and covert signs and symptoms in accordance with the standards of clinical nursing practice. 

1.2 Collects pertinent data using appropriate assessment techniques. 

1.3 Prioritizes data according to the patient’s immediate condition or needs. 

1.4 Involves the patient, family/significant others and appropriate health care providers in the collection of data when appropriate. 

1.5 Consistently uses clear, concise and effective written/oral communication and complies with departmental policies when sharing/documenting relevant patient care data. 

1.6 Identifies emergency/crisis situations, communicates such in a timely manner to appropriate health care team members, and responds appropriately when needed. 

2.0 Analyzes the assessment data to determine appropriate nursing diagnoses. 

3.0 Identifies expected outcomes individualized to the patient. 

3.1 Derives and documents realistic, appropriate clinical and educational patient-centered outcomes consistent with patient’s diagnoses, capabilities and expectations in accordance to the standards of clinical nursing practice. 

3.2 Develops outcomes as measurable goals which include a time estimate for attainment and provides direction for continuity of care. 

3.3 Mutually formulates outcomes with the patient, significant others and health care team when appropriate. 

4.0 Develops a plan of care that prescribes interventions to attain expected outcomes. 

4.1 Develops and documents an individualized plan of care that reflects the patient’s condition, prioritizes his/her needs, and provides for continuity of care. 

5.0 Implements interventions identified in the nursing and medical plan of care. 

5.1 Prioritizes patient care interventions based on fluctuating patient and unit needs. 

5.2 Effectively delegates appropriate patient care activities to co-workers with appropriate knowledge and skill level and ensures that co-workers have completed the delegated tasks in a timely manner.  

5.3 Educates patient and family regarding current illness, procedures, treatments, plan of care as well as health maintenance, promotion, and illness/injury prevention.  

5.4 In emergency/crisis situations, demonstrates effective decision making in accordance with standards of clinical nursing practice, re-prioritizes patient care needs, initiates appropriate response actions, and directs other team members to ensure a complete and coordinated response.  

5.5 Documents interventions according to departmental policy.  

6.0 Evaluates the patient’s progress toward the attainment of clinical and educational outcomes.  

6.1 Conducts systematic and ongoing patient reassessments and evaluations.  

6.2 Evaluates the effectiveness of interventions in relation to desired outcomes and includes the patient, significant others and appropriate health care providers in the evaluation process as needed.  

6.3 Incorporate ongoing assessment data in the revision of diagnoses, outcomes and the plan of care.  

6.4 Provides follow-up care in person via home visits and via telephone when needed and when appropriate.  

6.5 Documents patient’s response to interventions as well as revisions in diagnoses, outcomes and plan of care according to departmental policy.  

STANDARDS OF PROFESSIONAL PERFORMANCE  

1.0 Systematically evaluates the quality, cost, and effectiveness of nursing practice.  

1.1 Participates/leads quality improvement and/or research activities as appropriate to the individual’s position, education, skills, and practice environment.  

1.2 Uses the results of patient satisfaction, quality improvement and/or research data to initiate changes in practice.  

1.3 Accounts for completing daily patient classification data and incident reports in a timely manner.  

1.4 Participates in cost containment initiatives and practices.  

1.5 When two or more practice options exist that achieve the same quality of expected patient outcome, evaluates factors related to safety, effectiveness and cost when selecting the appropriate option.  

2.0  

2.1 Practices in compliance with established practice standards, policies, procedures, protocols, guidelines, statutes and regulations (example: DPH, JCAHO, Fire Code, OSHA, and DEA).  

 3.0 The nurse acquires and maintains current knowledge in nursing practice. Completes the following mandatory requirements: annual BLS certification, institutional mandatory education, e.g., safety regulations, infection control standards, etc., and departmental/unit specific competencies. Actively participates on unit or departmental based task forces, councils, or committees.  

4.0 The nurse contributes to the professional development of peers, colleagues, and others. 

4.1 Acts as a resource for new employees, float staff, and other unit team members.  

4.2 Assists in the orientation and/or acts as preceptor for new employees and/or nursing students. 

5.0 The nurse collaborates with client, significant others and health care providers in delivering client care.  

5.1 Communicates and consults with client, significant others and members of the health care team regarding required patient care.  

5.2 Works cooperatively and constructively with all departments and health care team members to establish an environment that supports the process of collaboration.  

5.3 Participates as an integral member of the health team during family/staff meetings, formal/informal shift rounds/reports, and medical/grand rounds.  

5.4 Coordinates appropriate internal and external referrals to assist patients to gain access to services, pre-approvals, etc.  

5.5 Coordinates discharge activities including arranging for home/agency referrals when necessary.  

Performs all other related duties as assigned. 

(The above statements in this job description are intended to depict the general nature and level of work assigned to the employee(s) in this job. The above is not intended to represent an exhaustive list of accountable duties and responsibilities required) 

KNOWLEDGE, SKILLS & ABILITIES (KSAs):