Registered Nurse

3 weeks ago


Towson Maryland, United States University of Maryland Medical System Full time
Job Description

ASSESS: Collaborates with patient, significant other and interdisciplinary health care providers to assess, plan, intervene, evaluate and document care in an individualized and age appropriate manner which promotes patients safety and healing and according to hospital policy. Completes initial assessment and screenings. Reassesses patient condition upon "handoff" and after therapeutic interventions. Assesses learning needs, readiness to learn and actual or potential barriers to learning.

EVALUATE: Interprets and utilizes clinical data and history in the plan of care. Evaluates patient progress towards goals. Communicates patient "handoff" with appropriate detail (i.e. shift report guided by the plan of care or any other pertinent documents). Follows through that patient care issues are addressed following chain of command. Recognizes changes in patient condition, communicates to appropriate health care personnel.

INTERVENE: Promotes and maintains a safe, clean and orderly environment. Acts as a patient advocate and upholds patient rights. Delegates work to care team. Responds effectively in emergency situations. Documents accurately in a legible and timely manner. Provides medical and nursing therapeutic interventions. Maintains a therapeutic relationship with patients and family while providing care. Incorporates education into daily patient activity (i.e. medication, equipment, food-drug interactions).

PLAN: Prioritizes and organizes work assignment and adjusts priorities based on changing situations. Recognizes and integrates patient special needs and individualizes care. Develops measurable plan of care goals congruent with evidenced based standards (e.g. core measures). Plans delivery of care according to patient acuity and staff competencies. Individualizes educational plan based on age, diagnosis, cultural and spiritual values. Consults and collaborates with other HealthCare professionals. Anticipates potential length of stay or discharge problems and adjusts plan.


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