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Nurse Practitioner
2 months ago
The Registered Nurse is a professional practitioner who assesses, manages, directs, and provides nursing care activities during the patient's hospital stay and coordinates planning with other disciplines utilizing a patient/customer driven approach.
Responsibilities and Requirements- Essential Functions:
- Performs comprehensive nursing assessment/reassessment.
- Establishes, coordinates and evaluates a plan of care based on analysis of assessment data, patient diagnosis, lab data, tests, procedures, physician orders, protocols and standards of care and other information as relevant.
- Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.
- Documents and or communicates nursing care and or changes in patient condition.
- Provides specialized care to patients at high risk for injury.
- Criteria:
- Performs age-appropriate admission assessment or transfer assessment. Obtains input from family/guardian when appropriate.
- Accurately and completely documents findings.
- Performs assessment of post-op/post-invasive procedure patients.
- Assesses and documents education and discharge needs of patient and family on admission and throughout hospitalization.
- Provides patient reassessment documenting pertinent observations according to the patient plan of care, changes in condition, status and/or diagnosis, response to care, procedures, etc., and standards of care.
- Identifies short and long term goals based on patient care needs.
- Formulates nursing interventions to achieve desired patient outcome.
- Collaborates with appropriate health team members for coordination of daily plan of care for assigned patients.
- Provides, coordinates and communicates patient care, including accurate Handoff Communication Reports.
- Administers and documents medications accurately according to policies and procedures.
- Monitors, maintains and documents accurate IV fluids and parenteral nutrition according to policies and procedures.
- Completes referrals as indicated by assessment data.
- Requests consultation for special needs, equipment, or information for patient and/or family.
- Provides patient/family education and discharge planning per documentation guidelines and protocol.
- Clarifies all physician orders as warranted.
- Acknowledges and implements physician orders in an accurate and timely manner as evidenced by documentation in the medical record.
- Assists physician with procedures/treatments as requested or delegates to Care Partner as appropriate.
- Documents "Readback" for all telephone / verbal orders.
- Takes telephone / verbal orders only in emergency situations.
- Recognizes changes in patient's condition and takes appropriate nursing actions.
- Involves the family/guardian when providing care and in decision-making as appropriate.
- Recognizes risks for patient and takes appropriate action.
- Incorporates use of Infection Control practices in daily care.
- Education:
- Associate's degree in Nursing or Bachelor's degree in Nursing.
- Experience:
- Minimum of 1 year of experience in a hospital setting.
- Certifications:
- Current RN licensure in the state of employment.
- BLS certification.
SSM Health is a Catholic, not-for-profit health system serving the comprehensive health care needs of communities across the Midwest – Illinois, Missouri, Oklahoma and Wisconsin. Our health care services include comprehensive medical and surgical care, specialist physician care, home care and hospice care.