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. |
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