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…