Assessment:

--    Performs appropriate nursing history and physical upon admission and on an 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 individualized 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 of patients, families, physicians and visitors.

--    Unit surveys consistently meet or exceed hospital benchmark.

--    Demonstrates customer service commitment to patients by maintaining flexibility in relation to patient assignment, shift assignment and work schedule.

--    All interactions are conducted in a professional manner.

--    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 phones promptly and professionally, 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.

Professional Conduct:

--    Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the department or 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).

Performance Improvement:

--    Demonstrates WHMC=s commitment to quality through the maximum individual effort of each employee.

--    Consistently works to improve identified unit-specific problems.

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

--    Uses established systems to document occurrences.

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 in-service programs.

--    Maintains licensure/certification as appropriate.

Qualifications:

A.     Minimum Education:                                               Graduate of approved nursing program.

B.     Minimum Experience:                                              1 year acute care experience preferred.

C.     Required Certification/Registration:                      Current California RN License; BLS; proficiency in both written and oral English.