Registered Nurse; RN

Under the guidance of the Nurse Manager the Staff RN is responsible for the provision of patient assessment , plan
-of- ca re, implementation of plan an d ev aluation of patient care utilizing the nu rs ing process to ensure quality of patient care . The Staff RN is responsible for carrying out duties as assigned and delivers care to patients in accordance with NHSC policy . The Staff RN constructs a nd updates a Nursing plan of care in conjunction with the medical plan of care that reflects comprehensive assessment of the patient and documents all Nurse patient interaction utilizing the   SOAP   format .

Utilizing a case management approach to care, the Staff RN evaluates the effectiveness of nursing care and updates the nurs in g p lan as indicated . The Staff RN also participates in quality assurance activities as directed and administers medications/treatments/immunizations prescribed by the physician in accordance with policy and procedu r e . The Staff RN is responsible for continuing educat i on .

• Uses the nursing process and guidelines to correctly complete and document relevant patient assessment on site.
• Promotes the family centered approach to patient care.
• Documents assessment via computer/chart.
• Applies knowledge of growth and development over the life span.
• Ensures appropriate referrals and follow - up.
• Provides telephone/walk - in triage in accordance with NHSC guidelines and policy.
• Assesses need for patient/family education.
• Utilizes the Child & Geriatric Abuse Policy in the Assessment process.
• Plans the nursing intervention of patients, demonstrates an understanding of the impact on family and community along with interdisciplinary team.
• Documents plans, goals, and patient outcomes.
• Utilizes available resources in planning of care.
• Participates in the establishment of department goals in the education of patients and their families.
• Evaluates and updates plan of care.
• Executes physician orders in accordance with nursing standards, NHSC policies and procedures and documents appropriately immunizations.
• Administers ordered medications in accordance with NHSC policy and procedure.
• Communicates appropriately with patient, families, peers and staff.
• Negotiates the plan of care with patient and family.
• Implements physician  standing order(s) .
• Synthesizes relevant findings in the application of the Nursing process and intervenes appropriately.
• Understands and demonstrates Universal Precaution measures in all patient care activities.
• Maintains necessary flowcharts on appropriate forms 22. Documents care implemented.
• Provides patient/family education in compliance physician order or assessed need.