The Registered Nurse provides care, treatment, counseling and health education to the hospitalized patient.  The RN is responsible for planning and coordination of care across the continuum.  This planning and coordination includes meeting and exceeding compliance with core measures, contributes to reduction in LOS, active participation with all aspects of quality, safety and performance improvement activities, collaboration with all the members of the multidisciplinary team in providing outstanding customer service to patients, family members, physicians and the public.  Meets and exceeds the Department of Health Service (DHS), The Joint Commission (TJC) and other regulatory requirements.

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.

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 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 department or on an as-needed basis or as determined by managment.
• 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 project 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 in-service programs.
• Maintains licensure/certification as appropriate.

Age-Specific Competencies

• Assessment
  • Adolescent
    • Assesses medication dosages for appropriateness based on patient size & weight. Informs MD as necessary.
    • Assesses for signs or symptoms of abuse or neglect.
  • Geriatric
    • Evaluates for age appropriate behavior, motor skills and physiological norms.
    • Assesses for signs/symptoms of abuse or neglect.
    • Assesses need for additional safety measure, e.g., side rails, posey vest, etc.
    • Assesses medication dosages for appropriateness based on patient size & weight. Informs MD as necessary.
    • Assesses skin integrity, develops plan of care as needed. Provides care according to plan/direction.
  • Adolescent, Middle Adult & Geriatric
    • Recognizes signs and symptoms of infection.
    • Demonstrates knowledge of medication dosage including indication, side effects and patient education.
    • Demonstrates understanding of insulin activity, diet and exercise.
    • Recognizes appropriate mobility limitation, e.g., use of abductor pillow, log rolling and traction.
• Knowledge of Growth and Development - Adolescent, Middle Adult & Geriatric:
  • Recognizes the need to provide reassurance and help in accepting body changes; is non-judgmental and accepting of behavior.
  • Recognizes the patient's need to have control over his/her environmental, knowledge and understanding of medical conditions including plan of care, prognosis and discharge plan.
  • Demonstrates knowledge of physiological deficits in association with the aging process, e.g., sensory, communicative, cognitive, behavioral.
• Range of Treatment - Adolescent, Middle Adult & Geriatric:
  • Demonstrates knowledge of CVA, cholecystectomy, UTI, pneumonia, diabetes, hip FX.

• Minimum Education: 
• Minimum Experience: 1 year acute care experience preferred.
• Required Certification/Registration: Current California License, BLS and PALS required.