1. ASSESSMENT
Performs complete patient assessment.
Recognizes significant changes in patient status and seeks appropriate resources.
Coordinates or collects physiologic monitoring data\: vital signs, monitor results, lab and diagnostic test results.
Performs ongoing assessment according to unit policy.
Documents assessment in compliance with hospital policy.
2. MAINTAINING PLAN OF CARE
Initiates the Patient Goal/Problem List or Clinical Path on admission.
Develops Plan of Care to support the patient goals and the medical plan of care.
Evaluates and documents the patient’s response to the plan of care and makes changes as appropriate.
Collaborates with multidisciplinary team to coordinate and plan provision of patient care.
3. MAINTAINING PATIENT TREATMENTS
Obtains and/or verifies all physician orders for procedures, medications, and therapies.
Assures the presence of consent and its documentation for procedures, therapies, and research protocols.
Assures the presence of appropriate supplies to perform the ordered procedure or therapy.
Performs or assists in procedures and therapies according to policy and procedures.
Assesses the patient’s needs for medication prior to administration.
Assesses patient allergies and medication incompatibilities.
Verifies, administers and documents medication according to hospital policy.
Evaluates and documents patient’s response to procedures, therapies and medications.
Monitors the patient care record for accuracy and completeness of data provided by care team members.
Coordinates and documents communication between patient, significant others and multidisciplinary team members in order to support the plan of care.
Ensures effective and wise use of resources, monitoring for cost containment.
Facilitates appropriate length of hospital stay.
4. TEACHING
Assesses the patient’s and significant other’s knowledge base, ability and readiness to learn based on their developmental age.
Identifies and utilizes multidisciplinary team members to provide comprehensive education for patients, self and others.
Incorporates teaching principles and methods appropriate to knowledge base, ability and readiness to learn and based on developmental age.
Demonstrates knowledge in area of teaching and available resources for patient and staff education.
Documents patient education in the patient care record.
Evaluates the teaching process.
Documents staff education per policy.
5. LEADERSHIP
Participates in peer review.
Provides learning opportunities and contributes to the orientation of team members, PRN personnel and students.
Identifies and implements educational opportunities for the staff.
Serves as a preceptor and role model for new employees and students.
Utilizes conflict resolution to promote a cohesive team.
Delegates assignments based on changes in census, staffing, patient, and unit needs.
Enforces hospital/department specific policies.
Maintains current knowledge of clinical and operational hospital policies and practice updates.
Engages in a therapeutic relationship with patients and develops healthy interpersonal relationships among colleagues.
Identifies the most important needs to be met each shift within the context of available resources.
Demonstrates accountability for their individual nursing practice.
Utilizes the mechanisms of the Professional Nursing Shared Governance (PNSG) organization to address nursing matters.
Demonstrates responsibility for being informed about the actions/activities of the PNSG.
Participates in activities of the PNSG organization.
6. UNIT-SPECIFIC COMPETENCIES
Provides care to patient population utilizing research findings and evidence based practice.
Unit required certifications must be obtained within six months of hire.
For any unit requiring CPI, it must be obtained within three months of hire.
Meets all unit-specific yearly skill requirements within acceptable timeframe.