The Registered Nurse (RN) is responsible and accountable for coordinating the activities and providing clinical expertise for the care of an assigned patient load, utilizing the Standards of Care of Nursing Practice. He/She provides direct patient care as needed during his/her shift. He/She contributes to the vision, mission, and strategic plan of the organization and is accountable for the Standards of Care and practice in the area of responsibility where clinical nursing is practiced.The RN must demonstrate knowledge of the principles of growth and development of the life span and possess the ability to assess data reflective of the patients status and interpret the appropriate information needed to identify each patients requirements relative to his/her age, specific needs, and to provide the care needed as directed in the units departmental policies and procedures. The RN will delegate to and oversee activities of the Licensed Nursing Assistant as appropriate and as defined in the Scopes of Practice by the New Hampshire Board of Nursing.
Current NH RN license
Current BLS certification
ACLS certification required within 18 months of hire
Basic Dysrhythmia course (30 hours or greater) required within 18 months of hire
PALS required within 2 years of hire
MOAB training within one year
Excellent interpersonal communications skills, organizational skills and time management skills
Essential Functions of the Job
Maintains required skills and competencies. Demonstrates current clinical practice and excellence in clinical practice as outlined in the skills competency tool and standards of nursing practice. Accepts professional responsibility and accountability for the quality of care for assigned patients. Upholds WMC mission and standards of practice. Is punctual and efficient in provision of care, meeting patientsâ€™ needs and advocating for the patient as necessary.
Attends and actively participates in daily team meetings (HUDDLES) on a regular basis to promote and facilitate communication of patient safety and risk concerns.
Assesses new admissions immediately upon arrival. Conducts a primary and secondary survey of the patient and documents findings per protocol. Ensures that the patient profile is complete and that medication reconciliation has been done on the patient (or completes it if not done). Completes the patient profile and assesses for its completion on each shift worked.
MEASURABLE GOAL: PAIN ASSESSMENT - Assesses the patient for pain and documents acceptable level of pain when applicable. Documents pre and post pain assessment when administering medications for pain. Ensures this information is present on the care plan as measured by audit using pain assessment audit tool. COMPLIANCE AS FOLLOWS: GREATER THAN OR EQUAL TO 95% = EXCEEDS; 85 - 94% = MEETS; 84% OR LESS = NEEDS IMPROVEMENT
MEASURABLE GOAL: CARE PLANS - Initiates and evaluates the care plan to reflect nursing assessment, implementation and evaluation of care. Care plan must be specific to patient and reflect physician plan of care and admitting diagnosis. Comorbidities must be specifically identified. Interventions specific to condition or disease (including co-morbidities). Progress to Goal must be documented when reviewing and evaluating the care plan. Measured by care plan audit tools. COMPLIANCE AS FOLLOWS: GREATER THAN OR EQUAL TO 95% = EXCEEDS; 85 - 94% = MEETS; 84% OR LESS = NEEDS IMPROVEMENT
Engages patient in plan of care through bedside shift report, communication of plan of care, actively participates in IDT meetings (to work towards discharge goals) and attends family conferences when scheduled.
Conducts hourly rounding to assess for patient safety and comfort. Uses AIDET regularly when interacting with patients.
Provides education to the patient and significant others related to their medications, health condition, treatment and discharge plan. Collaborates with the physician and Care Management as needed.
MEASURABLE GOAL: DISCHARGE INSTRUCTIONS - Completes the discharge instructions in a manner which can be understood by the patient. Completes â€œlast dose takenâ€ and â€œnext dose dueâ€ for all medications the patient is being discharged on. Discharged instructions are reviewed and signed by the pharmacist and/or the hospitalist or PCP prior to reviewing with patient. COMPLIANCE AS FOLLOWS: GREATER THAN OR EQUAL TO 95% = EXCEEDS; 85 - 94% = MEETS; 84% OR LESS = NEEDS IMPROVEMENT
Quantity of work meets the departmental demands and requirements. Demonstrates the ability to keep up with an increased volume of patients, as needed. Demonstrates knowledge of support systems to obtain assistance as needed.
MEASURABLE GOAL: Demonstrates accurate and complete documentation as evidence by 90% accuracy on the documentation audits. Less than 85% constitutes â€œNeeds Improvementâ€ and 95% or greater qualifies as â€œExceedsâ€.
MEASURABLE GOAL: Adhere to Medication Safety policies in regards to appropriately bar-coding medications and patient ID bands. Obtaining a witness whenever a barcode override for a medication to be administered is necessary. Meeting this standard would be using barcode override 3% (or less) of the time. Exceeds = 1.9% or less; Meet = 2.0% - 3.9% of barcode administration override; Needs Improvement = 4% or more
Accepts and satisfactorily completes miscellaneous duties as requested by House Coordinator, Department Manager and/or CNE.