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.
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%. Assesses safety needs based on age.
Prioritizes problems for immediate attention. Collaborates/Consults with other members of the health care team and ensures that a collaborative care plan is up-to-date and based on assessment. Documents patient progress toward goals/effectiveness of interventions. Determines correct nursing diagnosis and collaborative problems. Initiates care paths or protocols, as appropriate.
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. When in Charge Nurse role, makes assignments and facilitates continuity of care and patient safety.
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.
Ensures accuracy and thoroughness of medical record. Ensures accurate reflection of patient complaints and progress. Utilizes POC CIS to provide for quality, accuracy and efficiency of documentation. Completes accurate documentation of patient assessment, vital signs, plan of care, 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.
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. Rounds with admitting physician/ consulting physician(s). Communicates patient’s condition and progress to the physician daily and 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.
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.