The lead charge nurse is responsible for ensuring safe and appropriate care is provided to all patients on his/her unit(s) and during the assigned shift. Monitors for quality of care, conducts patient rounds to ensure patient satisfaction, and supervises staff to include addressing performance issues and completing performance evaluations.
Assesses Clinical and Psychosocial Patient Needs - 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%. •Assesses safety needs based on age. Rounds on patients each shift to ensure quality and safety measures are in place. This may include: lowrise beds, Telemonitors, bed alarms, curros caps, IV tubing date, etc. Assists other staff members with admissions, discharges, rounds with physicians, assists with bedside procedures, etc. based on the unit needs.
Establishes Patient Goals and Tracks Progress - •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 Patient-Centered, Outcomes-Focused Care - 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. •Guides staff to adhere 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. • Understands DPM and is able to guide staff through the process. Practice is based on understanding of initiatives/processes related to reaching benchmarks. •Completes quarterly competency/education updates. •Makes assignments and facilitates continuity of care and patient safety. Under the direction of the Patient Care Manager, helps drive quality initiatives. This includes data collection, staff education, and follow-up on progress of initiatives. This may also include participation on committees as needed. Meets with the patient care manager and other Lead Charges monthly to discuss goals and progress. Facilitates apparent cause analysis as appropriate and ensures follow up to the action plan
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.
Manages Key Components of the Clinical Record - •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.
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. •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.
Completes Bed Placement, Scheduling, and Staff Evaluations - Completes Bed Placement, Scheduling, and Staff Evaluations- places patients that are being admitted to the unit from ER, OR, Direct Admits, etc. Coordinates moving patients as needed to make availability for additional Neuro patients or NPCU patients. Collaborates closely with the transfer center. Updates discharges/pending discharges in Teletracking. Notifies Patient Care Manage when issues arise. Oversees, and ensures completion of Nurse, Nurse Assistant, and Telemontior schedules. Publishes schedule by the due date each month after final review by patient care manager. Reviews staffing holes that are sent by staffing office weekly, and assists in finding coverage. Provides input to Patient Care Manger for staff evaluations. Completes staff evaluations under the direction of the Patient Care Manger.