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RN- Same Day Surgery
3 months ago
Job Summary
Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate and family centered care for Same Day Surgery patients.
Job Specific Duties
- Supports the Service Recovery Program. Ensures that his/her behavior meets/exceeds acceptable Service Scores as measured by the Service Index. (SEI).
- Ensures completion of patient admission history. Prepares and accurately completes the discharge planning process accurately as per department and hospital policies and procedures.
- Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
- Follows physician's orders, administers, and reconstitutes medications when needed. Adheres to six rights of medication administration per medication administration policy.
- Ensures proper and safe sedation administration to patients and monitors recovery as per the Sedation Policy and Procedure.
- Performs reassessments as per policy and when there is a change in the plan of care or when an intervention is performed.
- Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
- Collaborates with a multi-disciplinary team in daily care planning, as appropriate, and fosters a Family Centered Care Environment
- Communicates the patient's progress including critical findings and changes in the patient's condition with the physician. Performs and documents discharge planning per policy.
- Ensures all surgical procedure documentation is obtained, labs, consents, advance directives, custody documentation in a timely and accurate manner.
- Accesses Electronic Medical Record (EMR) and performs charge reconciliation according to hospital policy and completes accurate and timely documentation in the patient's electronic health record.
- Communicates and documents critical lab results per hospital policy and procedures.
- Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician.
- Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care Environment.
- Provides education and documents on patient/family teachings on health-related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care, etc.).
- Promotes an "error free" working environment by consistently providing high-quality safe care as prompted (as per Universal Protocol Policy).
- Provides patient information and effectively completes the hand off process at shift change and patient reassignments. Utilizes Same Day Surgery checklist.
- Works to meet/exceed standards in achieving a 95% CEI by completing documents in a timely manner & being accountable to regulatory requirements of the DNV, CMS, DOH & other accrediting agencies.
- Accountable to optimize first case starts to prevent delay of patient care per departmental goal.
- Performs skin & structural assessment, takes measures to accommodate patient and ensures safe care, while ensuring no medication errors. Performs falls risk assessment & takes appropriate steps.
- Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH & other accrediting agencies.
- Assesses all body systems, ensure safe, effective, and efficient care delivery with emphasis on the absence of medication errors, avoidance of falls & reduction of pain post-op.
