JOB SUMMARY:

Provides direct nursing care in accordance with established policies, procedures and protocols of the healthcare organization.

RESPONSIBILITIES:

Implements and monitors patient care plans. Monitors, records and communicates patient condition as appropriate.
Serves as a primary coordinator of all disciplines for well-coordinated patient care.
Notes and carries out physician and nursing orders.
Assesses and coordinates patient's discharge planning needs with members of the healthcare team.

Assessment - An RN uses a systematic, dynamic way to collect and analyze data about a patient, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, sociocultural, spiritual, economic, and life-style factors as well.

-Initial assessment
-Re-assessment
-Focused assessment based on patient condition, setting and population

Problem Identification - Problem identification is the nurse�s clinical judgment about the patient�s response to actual or potential health conditions or needs.

Planning and Outcomes � Based on the assessment and problem identification, the nurse sets measurable and achievable short- and long-range goals in collaboration with the patient and family. Assessment data, problem identification, and goals are written in the patient�s care plan so that nurses as well as other health professionals caring for the patient have access to it.

-Establishing daily goals with the patient and family
-Formulating a plan of care
-Transition or Discharge planning

Implementation � Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge is assured. Care is documented in the patient�s record.

-Ensures patient safety
-Medication administration
-Provision of ordered treatments
-Patient/Family education
-Provision of nursing care
-Documentation in healthcare record

Evaluation � Both the patient�s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

Care Coordination � Actions initiated by nurses with patients, families, and/or members of their healthcare team to manage and correct the sequence, timing, and/or effectiveness of patient care from admission to discharge.

-Delegation
-Supervision
-Prioritization

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