Job Description
**Description**
_**Summary:**_
The competent Nurse, in the same or similar clinical setting, practices
independently and demonstrates an awareness of all relevant aspects of a
situation. Provides routine and complex care, with the ability to on long-
range goals or plans. Continues to develop the ability to cope with and manage
contingencies of clinical nursing. Makes appropriate assignments and delegates
to other care providers as a means to help manage the clinical situation.
_**Responsibilities:**_
* Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
* Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients.
* Addresses increasingly complex psychological, emotional, cultural, and social needs of patient and families in accordance with their level of practice.
* Using the appropriate protocol, administers medications and treatments; monitors for side-effects and effectiveness of the treatment prescribed.
* Documents patient history, symptoms, medication, and care given.
* Assess learning needs and provides education to patients, family members andor care givers; identify issues and resources.
CORE COMPETENCIES
Standard I: Utilizes the Nursing Process
* Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, spiritual, and development needs of patient and families
* Communicates findings to appropriate healthcare team members
* Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice
* Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
* Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s)
* Performs timely reassessment and documentation
* Must be able to perform unit-specific competencies based on the specific patient care need for the designated units patient population
Standard II. Patient Throughput & Patient Flow Process
* Anticipates and plans for admissiondischargetransfer needs to facilitate patient flow
* Utilizes appropriate systems of communication and tools to facilitate the discharge process
* Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy
Standard III. Unit Operations
* Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
* Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
* Assesses departmental staffing needs; actively participates in resourcing efforts.
* Educates and trains others on the operations, ethics, and regulations within the industry
Standard IV. Safe PracticeQuality CareRegulations
* Incorporates patient safety practicesguidelines to promote a safe environment resulting in positive patient outcomes
* Demonstrates accountability for nursing research and quality improvement activities
* Provides evidence-based nursing care
* Communicates patient information effectively across the continuum of care
* Educates and trains others on the operations, ethics, and regulations within the industry
* Knowledge of federal, state and local healthcare-related laws and regulations; ability to comply with these in healthcare practices and activities
TECHNICAL COMPETENCIES
Clinical Policies and Standards
* Follows a specific set of standards and associated clinical procedures
* Analyzes policy and standards documentation and ensures organizational compliance
* Provides feedback for improvement of procedures
* Assists in the development and implementation of specific procedures
* Works with control and monitoring mechanisms, tools and techniques
Health Information Documentation
* Shares experiences with maintaining paper and electronic patient documentation
* Walk through the steps and procedures for receiving, validating and updating patient records
* Describes the flow of information between various stations or units
* Discusses the functions, features and document flow of electronic documentation
* Transcribes verbal orders; explains techniques for ensuring their accuracy
* Explains health information documentation best practices and their rationale across health care practices
Medical Equipment
* Describes experience with basic medical equipment used in own unit or facility
* Uses standard diagnostic tools and techniques to resolves common equipment problems
* Educates patients about the appropriate use of home medical equipment
* Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
* Inspects, troubleshoots and evaluates incoming equipment
Medical Order Processing
* Shares experiences with processing medical orders for one or more groups of patients or conditions
* Describes functions and features of the system used to enter, validate, update and forward medical orders
* Discusses common errors, their sources and procedures for correcting
* Explains considerations for entering and following standing orders
* Differentiates between standing orders and preprinted orders and considerations for each
Patient Chart Reading and Interpretation
* Describes experiences in reading and interpreting patient charts for patients on unit and under own care
* Reviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissions
* Recognizes unexpected readings and alerts nursing or medical staff
* Relates examples of mis-readings or misinterpretations and lessons learned
* Reviews, discusses and validates own interpretation with others
Patient Safety
* Shares experiences with ensuring safety for one or more patient groups or settings
* Explains key features of safety guidelines and procedures for those groups and settings
* Listens and responds to safety inquiries from patients and family members
* Recognizes and addresses physiological and psychological signs of problems
* Describes considerations for patients who can cause to harm to self, versus harm to others
* Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real-time
**_Job Requirements:_**
**EducationSkills**
* Bachelor of Science Degree in Nursing, preferred
**Experience**
* 1 year of experience in the related nursing specialty preferred
**Licenses, Registrations, or Certifications**
* BLS required
* RN License in state of employment or compact
**_Work Schedule:_**
TBD
**_Work Type:_
**
Full Time
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Job Tags
Full time, Local area, Immediate start, Shift work,