Registered Nurse - Medical/Surgical 3W

Schedule: 7P-730A

Essential Functions and Responsibilities:

1.         Assesses the physical, psychosocial, and educational needs of the patient.

• Completes or reviews the admission assessment of the patient and utilizes it in the nursing process.
• Performs focused physical evaluation of the patient at the beginning and end of each shift, on patient transfer and/or upon discharge.
• Documents and reports abnormal physical findings to the physician and/or other appropriate personnel.
• Gives/receives reports on patients.
• Summarizes patient data and identifies appropriate nursing diagnosis/interventions and patient needs during shift, transfer and/or interim reporting.

2.         Plans and implements nursing care according to patient and family needs.

• Develops nursing plan of care, interventions and outcomes.  Revises and updates the nursing care plan as necessary.
• Sets/revises priorities for direct patient care activities by acuity/urgency of need.
• Determines and communicates nursing orders.
• Delegates tasks to others, making appropriate assignments.
• Oversees nursing care of all assigned patients and assures documentation is completed.
• Incorporates patient education into care plan as appropriate.  Provides patient education or contributes information for discharge planning.

3.         Makes appropriate interventions based upon individual patient needs.

• Administers medications according to hospital policy and procedure, documenting route, dose and time.
• Provides direct patient care including therapeutic treatments and diagnostic procedures according to patient and family needs.
• Implements physician's orders according to hospital protocols and procedures.
• Reports/receives assignments to ensure continuity of care. 
• Demonstrates clinical skills, performance of procedures, treatments and patient care.
• Directs patient education and documents outcomes, leads and coordinates education for the patient care partner.
• Leads and coordinates patient care activities in designated unit-based geographical assignment.
• Uses clinical judgment and integrates data for expected patient outcomes.
• Monitors care given and assures documentation is complete.
• Oversees patients discharge/transfer process and completes relevant information.

4.         Evaluates patient responses to nursing interventions.

• Documents patient responses to clinical interventions.
• Reviews and updates the patient's plan of care.  Communicates significant changes in patient status to others as appropriate.

5.         Assumes personal responsibility for quality patient care, patient satisfaction, environment and professional development.

• Promotes patient satisfaction, anticipates and responds to needs of others; provides assessment in a courteous manner; treats others with care and respect, maintaining privacy, confidentiality and dignity.
• Serves as patient/family advocate facilitating patient's ability to make informed decisions about their care.
• Participates in nursing or hospital performance improvement activities for monitoring and evaluating important aspects of care; nursing practices standards, and/or outcomes of care.
• Demonstrates professional behavior and interpersonal skills to reflect MCRMC mission, vision, and values.
• Participates in nursing research projects as requested.
• Complies with State Board of Nursing educational requirements.  Participates in organizational and departmental mandatory educational offerings, completing all requirements.
• Promotes own professional development through participation in education, unit-based meetings and committees.
• Complies with nursing and administrative policy and procedure manuals.

6.         Maintains a safe environment for patients, families, and staff.

• Complies with hospital and departmental safety policies.
• Documents actions and/or specifies the measures taken to ensure patient safety.
• Complies with infection control and universal precaution guidelines.

            7.         Performs other related job duties as assigned.