Registered Nurse Clinic - Childrens Services

Summary:

Provides general nursing care to patients in a clinic or medical office. Administers medication, prepares equipment and assists physicians/healthcare providers in the treatment of patients.

Responsibilities:

• Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process including assessment, diagnosis, planning, intervention and evaluation for assigned patients.
• Addresses psychological, emotional, cultural, and social needs of patient and families.
• Administering medications and treatments; monitoring for side-effects and effectiveness of the treatment prescribed; documenting patient history, symptoms, medication, and care given.
• Assess learning needs and provide education to patients, family members and/or care givers; identifying issues and resources.

Utilizes the Nursing Process

• Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, Spiritual, and development needs of patient and families
• Communicates findings to appropriate healthcare team members
• Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice. Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
• Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s). Performs timely reassessment and documentation
• Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population

Patient Throughput & Patient Flow Process

• Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow

Unit Operations

• Demonstrates good stewardship in proper use and maintenance of equipment and supplies

Safe Practice/Quality Care/Regulations

• Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
• Demonstrates accountability for nursing research and quality improvement activities
• Provides evidence-based nursing care
• Communicates patient information effectively across the continuum of care

Leadership

• Serves as a leader of patient care

Clinical Policies and Standards

• Follows a specific set of standards and associated clinical procedures
• Analyzes policy and standards documentation and ensures organizational compliance
• Provides feedback for improvement of procedures
• Assists in the development and implementation of specific procedures
• Works with control and monitoring mechanisms, tools and techniques

Health Information Documentation

• Shares experiences with maintaining paper and electronic patient documentation
• Walk through the steps and procedures for receiving, validating and updating patient records
• Describes the flow of information between various stations or units
• Discusses the functions, features and document flow of electronic documentation
• Transcribes verbal orders; explains techniques for ensuring their accuracy

Medical Equipment

• Describes experience with basic medical equipment used in own unit or facility
• Uses standard diagnostic tools and techniques to resolves common equipment problems
• Educates patients about the appropriate use of home medical equipment
• Ensures that all equipment and related supplies are in proper working order prior to use
• Inspects, troubleshoots and evaluates incoming equipment

Medical Order Processing

• Shares experiences with processing medical orders for one or more groups of patients or conditions
• Describes functions and features of the system used to enter, validate, update and forward medical orders
• Discusses common errors, their sources and procedures for correcting
• Explains considerations for entering and following standing orders
• Differentiates between standing orders and preprinted orders and considerations for each

Patient Chart Reading and Interpretation

• Describes experiences in reading and interpreting patient charts for patients under own care
• Reviews patients' charts for completion and accuracy; identifies and alerts to mistakes or omissions
• Recognizes unexpected readings and alerts nursing or medical staff
• Relates examples of mis-readings…