Registered Nurse - MedSurg

Location: Windber

Description

POSITION OVERVIEW:

This position must assume responsibility of meeting patient needs effectively and efficiently by applying complete nursing care to assigned patients. Care must be provided through all life stages of ages in medical, surgical, and telemetry areas of nursing. This position also provides direction and oversight to other staff members regarding patient care.

ESSENTIAL FUNCTIONS OF JOB: (other duties may be assigned)
PATIENT CARE:

Communicate pertinent information both orally and written to appropriate staff daily.

Report change in patient condition, fall, categories, transfers to other departments, staffing problems, etc. to health team daily.

Assist with decision-making and staffing.

Maintain patient confidentiality.

Use Care Manager by order entry process as necessary.

Complete incident reports as necessary.

MEDICATION ADMINISTRATION:

Administer medication and treatment daily as ordered by physician with proper documentation.

Follow the five patient rights: right medication, right patient, right route, right dose, and right time.

Complete documentation immediately following medication administration in patient’s chart.

Sign and date all documentation.

IV MANAGEMENT:

Ensure peripheral IV site and tubing is changed every 72 hours.

Ensure Heparin/saline locks are changed every 96 hours.

Document site and tubing changes.

Observe site for any signs of infiltration or infection and document.

Sign and date all documentation.

Maintain 100% compliance with all Hospital policies and procedures.

PATIENT ASSESSMENT:

Complete initial and on-going patient assessments to define individual patient needs.

Review assessment data and identify patient problems.

Develop patient plan of care and update daily.

Maintain concise documentation of all patient care that is provided every shift or as needed.

Complete nursing care plans daily.

Evaluate patient response to therapeutic interventions and document in nursing notes.

Ensure patient satisfaction through the distribution of questionnaires.

CLINICAL OVERSIGHT:

Provide clinical oversight of the nursing care process.

Serve as a resource for staff including the licensed practical nurses, nurse aides, and other ancillary staff.

Delegate nursing care duties as appropriate for the scope of practice of assignee.

Periodically serve as the charge nurse responsible for the overall functioning of the nursing unit.

Observe staff with patients regularly to ensure patient satisfaction.

Direct staff as needed to ensure 100% compliance with all Hospital policies and procedures.

Evaluate patient care provided by other staff members through coaching.

Reinforce Hospital policies and procedures to ensure staff continually deliver quality patient care.

Assist in orientation of new and transferred staff for three months as needed.

Provides education to patients, care partners, and other staff members as needed within scope of practice.

Evaluate patient, care partner, and other staff member’s understanding of techniques by successful demonstration.

Document procedure upon completion of demonstration.

Offer pre/post testing with new techniques.

Assist in identifying the educational needs of the Unit.

DISCHARGE PLANNING:

Coordinate patient discharge planning.

Begin planning patient discharge upon admission.

Complete discharge summary plan as outlined on physician discharge orders.

Review discharge plans with patient and/or care partner.

Ensure patient and/or care partner understands discharge instructions.

Document discharge planning and patient and/or care partner understanding in patient chart legibly.

QUALITY IMPROVEMENT:

Assist with departmental evaluation and improvement of nursing practices.

Participate in quality improvement, fire safety, infection control, etc.

Support change to improve patient care through suggestions offered by patient response forms.

Participate in departmental committees or projects.

Accept and respond to constructive criticism by improving performance.

Up to date with all Hospital policies and procedures.

Ensure staff follows appropriate Hospital policies and procedures.

Complete documentation following all codes and ensure documentation is accurate and legible.

REGULATORY COMPLIANCE:

Must…