Registered Nurse

Registered Nurse
Job Summary
Under the guidance of the Nurse Manager, the Staff RN is responsible for the provision of patient assessment, plan-of-care, implementation of plan and evaluation of patient care utilizing the nursing process to ensure quality of patient care. The Staff RN is responsible for carrying out duties as assigned and delivers care to patients in accordance with policy. The Staff RN constructs and updates a Nursing plan of care in conjunction with the medical plan of care that reflects comprehensive assessment of the patient and documents all Nurse patient interaction utilizing the "SOAP format. Utilizing a case management approach to care, the Staff RN evaluates the effectiveness of nursing care and updates the nursing plan as indicated. The Staff RN also participates in quality assurance activities as directed and administers medications/treatments/immunizations prescribed by the physician in accordance with policy and procedure. The Staff RN is responsible for continuing education.
ESSENTIAL FUNCTIONS and PRINCIPAL ACCOUNTABILITIES

• Uses the nursing process and guidelines to correctly complete and document relevant patient assessment on site
• Promotes the family centered approach to patient care.
• Provides clinical supervision of LPN's, Health Assistants/Medical Assistants
• Documents assessment via computer/chart.
• Applies knowledge of growth and development over the life span.
• Ensures appropriate referrals and follow-up.
• Provides telephone/walk-ins triage in accordance with guidelines and policy.
• Assesses need for patient/family education.
• Utilizes the Child & Geriatric Abuse Policy in the Assessment process.
• Plans the nursing intervention of patients, demonstrates an understanding of the impact on family and community along with interdisciplinary team.
• Documents plans, goals, and patient outcomes.
• Utilizes available resources in planning of care.
• Participates in the establishment of department goals in the education of patients and their families
• Evaluates and updates plan of care.
• Executes physician orders in accordance with nursing standards, policies and procedures and documents appropriately immunizations.
• Administers and orders medications in accordance with policy and procedure.
• Communicates appropriately with patient, families, peers and staff
• Negotiates the plan of care with patient and family
• Implements physician "standing order(s).
• Synthesizes relevant findings in the application of the Nursing process and intervenes appropriately
• Understands and demonstrates Universal Precaution measures in all patient care activities
• Maintains necessary flowcharts on appropriate forms
• Documents care implemented
• Provides patient/family education in compliance physician order or assessed need.
• Implements and documents education and patient/family understanding of education given.
• Assists and participates in Department, General Staff and community education services.
• Participates in referral and follow-up: evaluates the need to re-educate.
• Acts as resource person to community and staff.
• Evaluates assessment and plan for each patient/family
• Documents outcomes
• Assesses need for change in care plan and implements change.
• Evaluates outcome along with interdisciplinary team.
• Participates in quality improvement efforts as assigned.
• Complies with Patient Bill of Rights.
• Alerts administration to quality issues.
• Documents patient complaints in accordance with guidelines
• Perform duties as assigned.
• Directs the patient care team as assigned.
• Assigns patient care as directed
• Assumes "Charge Nurse responsibilities as assigned or in the absence of the Department Nurse Manager.
• Participates in the evaluation of ancillary staff as appropriate.
• Assists in the orientation of new staff.
• Assumes responsibility for own professional growth and development.
• Serves on committees as necessary.
• Functions as resource agent in the patient care, specialty area and orientation of students.
• Works effectively with management.
• Maintains required certifications and license.
• Cooperates effectively with management.
• Creates and maintains an environment conducive to teamwork.
• Maintains a professional appearance.
• Maintains a professional attitude.
• Treats patient, staff and peers with respect.
• Maintains confidentiality in accordance with policy
• Promotes philosophy and policies.
• Self educates in all Policy and Procedure.
• Self educates in all requirements under JCAHO, HIPAA and State regulations.
• Follows Policy and Procedure with special consideration of security, fire and safety procedures and Universal Precautions.
• Reports all concerns regarding safety and hazardous conditions immediately.
• Maintains confidentiality in accordance with policies.
• Arrives to work station at scheduled starting time ready to work.
• Records/Time and attendance in accordance with expectations accurately.

QUALIFICATIONS

• Graduate of an accredited school of Nursing AAS accepted, BSN preferred.
• Valid New Jersey R.N. license, BCLS
• At least one (1) year adult medical/surgical experience required, management of geriatric patients, Community Nursing experience preferred.
• For Pediatrics Department RN , at least one (1) year pediatric medical/surgical experience required, management of pediatric patients, Community Nursing experience preferred.