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RN, Registered Nurse
2 months ago
The Clinical 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.
Key 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 and/or care givers; identify issues and resources.
- 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 unit's patient population.
- Anticipates and plans for admission/discharge/transfer 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.
- 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.
- Incorporates patient safety practices/guidelines 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.
- 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.
- 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.
- Describes experience with basic medical equipment used in own unit or facility.
- Uses standard diagnostic tools and techniques to resolve 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.
- 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.
- 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.
- 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.
- Lists 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.
- Bachelor of Science Degree in Nursing, preferred.
- 1 year of experience in the related nursing specialty preferred.
- BLS required.
- RN License in state of employment or compact.
