Registered Nurse RN MedSurg PRN

Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs. Reviews patient history and physical with patient/family, ensures completion within appropriate timeframe, reviews diagnostics and laboratory data, and reports abnormal results.

Formulates a plan of care, including the discharge plan, and initiates a plan based on assessment data and patient‑specific needs. Sets realistic, measurable goals with patient and family. Collaborates with multidisciplinary team.

Implements the plan of care through direct patient care, coordination, delegation and supervision of the health care team. Provides care per physician orders and nursing plan, complies with policies, standards, and regulatory requirements. Delegates appropriately and provides nursing supervision.

Evaluates patient and family response to care and teaching, revises plan as needed. Evaluates patient progress toward goals and expected outcomes in collaboration with health care team.

Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and follows policy. Notes physician orders accurately and timely.

Provides care based on best evidence, may participate in research activities. Participates in unit or facility shared leadership. Engages in education and orientation of personnel, patients, families. Supports growth of others through precepting and mentoring.

Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Participates in improvement of national nursing quality indicators and outcomes.

May supervise staff and workflow within the department.