| Summary: Plans for, delivers, documents and evaluates nursing care of patients in an assigned area in terms of their individuals needs, according to provider’s orders and in conformance with approved and recognized nursing standards of care, recognized nursing techniques, procedures and administrative policy. Directs activities of assigned nursing personnel in such care. Observes, assesses and reports on the condition of patients. Maintains accurate and timely documentation of care reflecting patient’s condition, treatment, and response to care. Upholds the mission, vision, values, and customer service standards of The MetroHealth System. Responsibilities: I. Patient-Centered Care
- A. Provides direct nursing care to patients according to the assignment and to individual needs of the patient; assesses health-related needs based on biological data, patient history, and other existing data, such as medical chart reports or computerized medical record.
- B. Provides age-appropriate care for the population(s) served. Possesses the ability to understand and react effectively to the unique needs of each population and to assess, treat and care for these patient groups. Generally the age groups served are:
- C. Provides care in a manner which enhances patient satisfaction and respects cultural diversity.
- D. Is specifically responsible for proper care of assigned patients and is generally responsible for all patients on the unit or in the clinic/practice to which assigned; assists in maintaining a comfortable, orderly, clean and safe environment.
- E. Encourages patients to be actively engaged in their plan of care and participate in exercising their rights and responsibilities
II. Leadership & Professionalism
- A. Identifies own learning needs, sets learning goals and actively pursues required knowledge and skills.
- B. Attends and actively participates in in-service programs. Attends unit-specific in-services.
- C. Assists in orientation and instruction of new personnel; explains and demonstrates techniques and methods.
- D. Assists in checking and maintaining an adequate level of supplies; utilizes supplies in a cost-effective manner.
- E. Works with employees of other classifications and supervises them in the performance of their work assignments.
- F. Assists in checking and maintaining an adequate level of supplies; utilizes supplies in a cost-effective manner.
- G. Works with employees of other classifications and supervises them in the performance of their work assignments.
III. Evidence-Based Practice
- A. Applies the nursing process in assessing patients/reviews presenting health problems, incorporates evidence-based practice into clinical practice, communicating assessment findings to other health team members, establishing priorities of patient needs, including age and developmental specific needs, developing a plan of care/treatment plan, initiating nursing intervention, and evaluating effectiveness of the care plan/after visit summary within specified time frames and planning for discharge/home-going instructions.
- B. Plans and carries out teaching programs for specified patients and families: assesses patient’s learning needs with consideration for readiness and ability to learn, level of understanding and prior knowledge and basic learning principals; develops and implements an individualized teaching plan; evaluates and documents the outcome of patient education; makes appropriate referrals to external resources.
IV. Quality Improvement & Safety
- A. Demonstrates adherence to policies related to the safe handling of hazardous/infectious wastes and materials; upholds standards of universal precautions.
- B. Knows disaster plan and responds calmly to disaster situations.
- C. Assists in analyzing and evaluating the nursing/patient care required and given in the assigned unit; participates in Performance Improvement initiatives, makes recommendations to nurse manager or practice/clinical coordinator for improvements; identifies trends and/or patterns in relation to patient care issues.
V. Informatics & Technology
- A. Maintains accurate and complete records and reports on documentation of patients’ conditions, active problems, treatments, medications and outcomes of same to reflect current status.
- B. Is responsible for a general understanding and use of the Patient Classification System or EPIC and other automated systems, such as HIS, and the laboratory and radiology information systems.
VI. Communication Teamwork & Collaboration
- A. Guides and directs assigned nursing personnel; assigns appropriate duties to staff members, supervises their work and instructs them in its proper performance, evaluates their progress and performance.
- B. Collaborates with physicians and other members of the health care team to address individual patient care issues through the process of mutual information sharing, discussion and decision making.
- C. Coordinates nursing plan of care/treatment plan with medical plan of care.
- D. Consults with other nurses for joint problem solving and setting of mutual goals related to patient care issues.
- E. Collaborates with peers and other members of the health care team to address issues related to unit operations; participates in interdisciplinary performance improvement activities.
- F. Collaborates with the interdisciplinary team in developing a discharge plan/home-going instructions.
- G. In the ambulatory areas: reviews after-visit summary with patient and/or family member.
VII. Systems-Based Practice
- A. Remains current with contemporary nursing techniques and standards, adhering to national standards and ANA Code of Ethics.
- B. Serves on committees and participates in activities within the nursing service or medical operations as appropriate.
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