Responsibilities

Performance Standard

Assessment:

§  Performs appropriate nursing history and physical upon admission and ongoing basis.

§  Collects and documents patient data.

§  Interviews patients and significant others and completes a history documentation.

§  Documents signs and symptoms that indicate actual and potential problems.

§  Incorporates information in the written assessment from families/significant others and members of the health care team.

§  Assesses safety of the patient care environment.

§  Documents patient/family teaching needs in the patient care plan.

Planning:

§  In conjunction with the patient and family, develops individual patient care plan.

§  Identifies short and long term goals, including discharge planning consistent with established patient care.

§  Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.

§  Provides continuity of care by communicating the plan of care and diagnostic data through the shift report, in accordance with the unit’s guidelines.

§  Involves family members and other health care team members in the development of the plan of care as able and appropriate.

§  Revises the initial patient care plan to the changing needs of the patient.

Implementation:

§  Provides direct nursing care based on the plan of care and established priorities.

§  Sets priorities and gives nursing care based on the patient’s needs.

§  Implements the medical care plan as delegated.

§  Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).

§  Writes patient discharge plan and makes appropriate referrals.

§  Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.

§  Coordinates the activities of other disciplines of the health team to implement the individual care plan.

Evaluation:

§  Evaluates and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.

§  Revises plan of care based on evaluation.

§  Documents the response of the patient to the medical care plan.

§  Documents the response of the patient to nursing interventions.

§  Recognizes alterations in physiological and psychosocial status.

§  Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.

§  Documents revision of the goals and plan of care to meet the changing needs of the patient.

Customer Service

§  Consistently strives to implement the unit’s customer service standards and to exceed the expectations and satisfaction levels of patients, families, physicians and other customers.

§  As observed, all interactions are conducted in a professional manner; is supportive and consistently demonstrates the Target 100 standards.

§  Unit surveys consistently meet or exceed hospital benchmark.

§  Verbal and written feedback from patients, family members/significant others, medical staff, visitors and co-workers indicates behavior conducive to positive guest relations.

§  Consistently exhibits appropriate phone protocol (e.g., answers phone promptly, is courteous and helpful).

§  Interacts with other departments for problem resolution and quality patient care.

§  Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.

§  Makes rounds to assigned patients; anticipates patients’ needs and answers/responds to the patients’ call lights or paging promptly.

Performance Improvement

§  Serves as a role model in implementing the PDCA (Plan, Do, Check, Act) methodology.

§  Consistently works to improve identified unit-specific problems.

§  Consistently works to improve identified hospital-wide system problems.

§  Uses established systems to document occurrences.

Professional conduct

§  Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the unit on an as-needed basis or as determined by management.

§  Follows attendance and all other established hospital and department policies.

§  Demonstrates the philosophy of the team concept.

§  Participates in staff meetings with suggestions that enhance the work environment and increase productivity.

§  Communicates well with supervisor, reporting problems with equipment, supplies or procedures.

§  Requests assistance as appropriate.

§  Complies with all safety and infection control standards.

§  Maintains confidentiality as related to job responsibilities.

§  Exhibits willingness to resolve problems as they arise.

§  Consistently projects positive professional image through appearance and behavior.

§  Attends 75% of staff meetings or reads and initials minutes.

§  Completes assigned work within shift.

§  Complies with time and attendance policy (i.e., KRONOS).

Professional growth and development

§  Completes Annual Updates and Ethics Training within established time frames.

§  Completes general and departmental orientation within established time frames.

§  Attends 80% of unit staff meetings and inservice programs.

§  Maintains licensure/certification as appropriate.

Qualifications:

A.      Minimum Education:

B.      Minimum Experience: One year acute care RN experience preferred.

C.      Required Certification/Registration: Current California R.N. license, BLS and PALS required.