Description Summary: Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients. Patient Care Planning • Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment. • Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference. • Reviews and updates nursing care plan and collaborates with team members as changes occur. • Patient Care Provision • Implements patient care as planned in nursing care plan and interdisciplinary care plan. • Provides safe and therapeutic care and seeks resources when appropriate. • Safely performs and accurately documents procedures, consistent with established nursing policy and procedure. • Patient Care Evaluation • Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team. • Evaluates progress toward nursing goals and revises goals as needed on a weekly basis. • Completes nursing progress note for assigned patients on a daily basis. • Completes nursing flow sheets for assigned patients on a daily basis. • Teaching • Evaluates education needs of patient and significant others and documents their response to teaching. • Acts as role model for health care students and other team members. • Assists in the orientation of new staff by sharing knowledge and experience. • Patient Care Communication• Reports and documents accurately and concisely to appropriate persons the patient's condition. • Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others. • Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed. • Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives. CORE COMPETENCIES 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). Performs timely reassessment and documentation • Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population Standard II. 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 • Assesses departmental staffing needs; Educates and trains others on the operations, ethics, and regulations within the industry Standard IV. Safe Practice/Quality Care/Regulations • Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes • 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 TECHNICAL COMPETENCIES Clinical Policies and Standards • Follows a specific set of standards and associated clinical procedures • Analyzes policy and standards documentation and ensures organizational compliance • Provides feedback for improvement of procedures • Assists in the development and implementation of specific procedures • Works with control and monitoring mechanisms, tools and techniques Health Information Documentation • Shares experiences with maintaining paper and electronic patient documentation • Walk through the steps and procedures for receiving, validating and updating patient records • Describes the flow of information between various stations or units • Discusses the functions, features and document flow of electronic documentation • Transcribes verbal orders; explains techniques for ensuring their accuracy • 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 • Discusses common errors, their sources and procedures for correcting • Explains considerations for entering and following standing orders • Differentiates between standing orders and preprinted orders and considerations for each Patient Chart Reading and Interpretation • Describes experiences in reading and interpreting patient charts for patients on unit and under own care • Reviews patients’ charts for completion and accuracy; identifies and alerts to mistakes or omissions • Recognizes unexpected readings and alerts nursing or medical staff • Relates examples of mis-readings or misinterpretations and lessons learned • Reviews, discusses and validates own interpretation with others Patient Safety • Shares experiences with ensuring safety for one or more patient groups or settings • Explains key features of safety guidelines and procedures for those groups and settings • Listens and responds to safety inquiries from patients and family members • Recognizes and addresses physiological and psychological signs of problems • Describes considerations for patients who can cause to harm to self, versus harm to others • Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real time Meets all requirements identified in this position description. Requirements: Experience: 1 year of experience in the related nursing specialty preferred. Education: Bachelor of Science Degree in Nursing preferred. New hires are precepted by a designated trained staff member and initial on-boarding requirements are validated through successful completion of the designated organizational entry competency validation and a Perinatal Department -specific competency validation. Licenses/Certifications/Registrations: RN Licensure in state of employment or compact. Current certification from NCC Electronic Fetal Monitoring (C-EFM) or one of the following AWHONN courses: within 90 days of hire for new graduates and experienced nurses new to the specialty then required to maintain course certification thereafter. Work Schedule: 7PM - 7AM Work Type: Full Time EEO is the law - click below for more information: If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact us at (844) 257-6925.