Registered Nurse RN Surgical Observation DS

Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs. Reviews patient history and physical with patient/family, assures completion within appropriate timeframe, and reviews information from other health care team members. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and policy.

Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs and the medical plan of care. Goals for patient are realistic, measurable, and developed in conjunction with the patient/family. Considers the physical, cultural, psychosocial, spiritual and educational needs of the patient. Plans care in collaboration with multidisciplinary team members and revises the plan as patient status changes.

Implements the plan of care through direct patient care, coordination, delegation and supervision of the health care team. Provides care based on physician orders and the nursing plan of care, complying with policies, standards, and regulatory requirements. Delegates appropriately and provides nursing supervision to other licensed nurses and personnel. Promotes continuity of care through accurate and complete communication to other caregivers.

Evaluates the patient’s and family’s response to care and teaching, revising the plan of care as needed. Evaluates patient progress toward goals and expected outcomes collaboratively with the health care team. Evaluates effectiveness of patient teaching.

Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy, reflecting objective/subjective data, nursing interventions and patient response to treatment. Notes physician orders accurately and promptly.

Provides care based on best evidence available and may participate in research activities within clinical practice. Participates in unit or facility shared leadership, education, role development, orientation of facility personnel, patients, families and visitors. Supports growth of others through precepting and mentoring when appropriate.

Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Actively participates in improvement of national nursing quality indicators and outcomes. May include participation in professional organizations.

In some roles, this position may supervise staff and workflow of the department.