Under the direction of the Charge Nurse, Patient Care Manager, Director, and Vice President of Patient Care, the Clinical Nurse (I - V) administers individualized age-appropriate patient care to the neonate, pediatric, adolescent, geriatric and adult patient according to the established nursing standards and Nurse Practice Act of Missouri.
Assesses Clinical and Psychosocial Patient Needs. - Accurately and thoroughly completes assessments. Accurately reconciles and documents medications during care transitions. Uses health information from a variety of appropriate resources. Assesses pain and reassesses according to policy and documents at greater than 90%. Provides emotional and psychological support to patients and families.
Establishes Patient Goals and Tracks Progress. - Prioritizes problems for immediate attention. Collaborates/Consults with other members of the health care team as needed to provide care. Performs assessment of each patients needs and utilizes the information in implementing an individualized plan of care. Assesses and determines patients progress towards discharge criteria. Initiates protocols, as appropriate.
Provides Patient-Centered, Outcomes-Focused Care. - Provides direct patient care within interpreted guidelines of Nursing Practice Act of Missouri. Incorporates new technologies to provide safe care. Adheres to Medical Center policies/procedures for care. Evaluates age specific/appropriate motor skills and psychological development Uses interview and communication techniques appropriate for age. Uses equipment appropriately based on age and size of patient. Identifies any unique physical and or emotional needs and determines what other support systems are required for care. Practices evidence based nursing. Is knowledgeable about the nursing quality scorecard and practice is based on understanding any initiatives/processes related to reaching benchmarks. Completes quarterly competency/education updates.
Educates and Engages Patients and Their Families. - Develops education plan based on patient/family knowledge deficits, diagnosis, treatment regimen and community support/resources. Monitors and documents patient/family progress in understanding care needs post discharge and the ability to care for self. Uses adult learning principles. Employs appropriate use of teaching aids and technology. Makes appropriate referral for continued education, as care transitions. Develops a therapeutic relationship with patients and families. Answers any questions/concerns from patient and/or family.
Manages Key Components of the Clinical Record. - Ensures accuracy and thoroughness of medical record. Ensures accurate reflection of patient complaints and progress. Communicates all abnormal test results to anesthesia and/or surgeon and follows through on orders obtained and documents appropriately. Completes accurate documentation of patient assessment, ARRA data, vital signs, medication administration and communication with provider. Bar coding is at or greater than 98% (if applicable). Ensures accurate information follows patient at discharge and through care transition. Ensures all anesthesia orders are discontinued per departmental protocol. Ensures 100% order accuracy, verification and initiation of anesthesia protocol.
Coordinates Care With Inter-Professional Caregivers. - Participates in clarifying and communicating medical information to patients, family and staff. Relays all pertinent health information, including home medications, to attending physician. Report/handoffs are conducted at the bedside using SBAR. Assists surgeon, MDA, consulting physician(s). Communicates patient’s condition and progress to the physician as indicated to keep physician informed. Is prepared and organized when discussing plan of care with the physician either by phone or in person. Verifies attending physician and consultants have consistent information. Acknowledges standing orders per department guidelines. Activates anesthesia pre-orders per department guidelines.
Facilitates Safe Patient Transition to Next Care Setting. - Consistent with POC, plans for safe community transition in collaboration with appropriate inter-professionals. Provides for a thorough verbal handoff to receiving entity. Provides for accurate medication reconciliation.