Provides routine and complex care, with the ability to on long-range goals or plans. Continues to develop the ability to cope with and manage contingencies of clinical nursing. Makes appropriate assignments and delegates to other care providers as a means to help manage the clinical situation.
Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients.
Documents patient history, symptoms, medication, and care given.
Assess learning needs and provides education to patients, family members and/or care givers; Standard I: Utilizes the Nursing Process
Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural, spiritual, and development needs of patient and families
Communicates findings to appropriate healthcare team members
Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice
Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s)
Must be able to perform unit-specific competencies based on the specific patient care need for the designated unit's patient population
Unit Operations
Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
Educates and trains others on the operations, ethics, and regulations within the industry
Safe Practice/Quality Care/Regulations
Demonstrates accountability for nursing research and quality improvement activities
Provides evidence-based nursing care
Communicates patient information effectively across the continuum of care
Educates and trains others on the operations, ethics, and regulations within the industry
Knowledge of federal, state and local healthcare-related laws and regulations; ability to comply with these in healthcare practices and activities
Clinical Policies and Standards
Analyzes policy and standards documentation and ensures organizational compliance
Assists in the development and implementation of specific procedures
Works with control and monitoring mechanisms, tools and techniques
Health Information Documentation
Describes the flow of information between various stations or units
Discusses the functions, features and document flow of electronic documentation
Explains health information documentation best practices and their rationale across health care practices
Medical Equipment
Describes experience with basic medical equipment used in own unit or facility
Uses standard diagnostic tools and techniques to resolves common equipment problems
Educates patients about the appropriate use of home medical equipment
Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
Inspects, troubleshoots and evaluates incoming equipment
Medical Order Processing
Shares experiences with processing medical orders for one or more groups of patients or conditions
Describes functions and features of the system used to enter, validate, update and forward medical orders
Describes experiences in reading and interpreting patient charts for patients on unit and under own care
Recognizes unexpected readings and alerts nursing or medical staff
Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real-time
Bachelor of Science Degree in Nursing, preferred
1 year of experience in the related nursing specialty preferred
Licenses, Registrations, or Certifications
Full Time
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