The Staff Nurse reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.
- The registered professional nurse assumes accountability and responsibility for the individualized, age-specific care of a patient along the continuum from admission to discharge. She/He gives direct care to assigned patients and assists with other patient care when necessary. The registered professional nurse’s decisions and actions on behalf of the patient/family are determined in an ethical manner. She/He collects and analyzes the assessment data in determining nursing diagnoses, collaborates with the patient/family and other health care team members, develops a plan of care to attain realistic outcomes, provides education founded on evidence-based practice, and systematically evaluates the quality and effectiveness of nursing practice.
Responsibilities:
- Assess and records patient status and identifies patient care needs upon admission/point of care entry.
- Organizes the assessment health data so that it is accurate, complete and accessible.
- Identifies problems that need immediate attention.
- Validates diagnoses with patient/family and other health care team members.
- Documents diagnoses in a manner that facilitates the determination of expected outcomes and plan of care.
- Initiates Problem List at the time of admission and updates as needed. Incorporates principles of age-specific care into the patient’s plan of care.
- Documents that the patient’s individualized plan of care has been discussed with and agreed upon by the patient/family.
- Begins plans for discharge at time of admission; consults with patient/family and health care team members regarding discharge plan.
- Identifies patient teaching needs on admission and throughout hospital stay.
- Arranges conferences with patient and/or family and other members of health team when indicated to plan care.
- Prioritizes and organizes nursing interventions that are evidence based and reflective of established standards of care.
- Provides individualized, mutually agreeable, patient and family education that is founded on evidence-based practice and research guidelines.
- Documents all assessments, interventions and patient responses.
- Reviews consistently the patient’s health data to keep the Plan of Care updated.
- Assures that revisions to the plan of care are systematic and ongoing and are driven by measurable realistic goals.
- Documents the patient’s progression toward identified outcomes
- Identifies unmet outcomes and provides direction for continuity of care.
- Reassesses nursing actions for effectiveness in achieving desired outcomes.
- Communicates with patient/family and health care team members re: patient care and nursing’s role in the provision of care.
- Collaborates with patient/family and healthcare team members re: the patient’s progress/plan of care.
- Presents relevant patient information at multidisciplinary meetings/conferences for feedback from peers.
- Makes appropriate referrals as needed for continuity of care.