Job Description
Delivers and ensures patient care by assessing and diagnosing patient's condition, developing a plan of care, and evaluating patient's response to care. Participates in patient education and discharge planning. Collaborates with, coordinates, and guides designated care team members in planning patient care and achieving goals.
Job Responsibilities
- Develops and evaluates plan of care.
- Systematically assesses patient's knowledge base and physical, psychosocial, and spiritual health through interviews, examinations, and data collection.
- Consults with the multidisciplinary healthcare team regarding assessment findings.
- Creates an individualized plan of care based on patient problems, anticipated stay, and input from patient, family, and team members.
- Communicates patient status changes to the care team and other providers.
- Collaborates to adjust the plan of care as needed.
- Provides and/or delegates patient care according to the plan and protocols.
- Utilizes clinical resources and provides rationale for care decisions.
- Conducts rounds, provides emergency care, and administers medications.
- Operates necessary equipment per manufacturer instructions.
- Performs procedures such as dressing changes, feeding, and pre/post-operative care.
- Monitors infection control standards.
- Ensures patient safety following guidelines.
- Documents patient care.
- Records entries with date, time, and signature.
- Completes assessments and documents responses and interventions.
- Performs vital signs and pain assessments regularly.
- Prepares transfer and perioperative assessments as required.
- Maintains observation and intake/output records.
- Initiates healthcare referrals collaboratively.
- Provides patient education.
- Identifies learning needs and educates patients and families.
- Develops and documents teaching plans and conferences.
- Participates in Quality Improvement processes.
- Contributes to unit goals, attends training, and reports incidents.
- Involves in problem-solving and corrective actions.
- Participates in staff meetings and conferences.
- Represents the unit on committees and submits continuing education records.
- Performs charge nurse and preceptor duties as assigned.
- Performs related duties as required.
ADA Essential Functions
Job Qualifications
- Graduate from an accredited School of Nursing. Bachelor's Degree preferred. Enrolled in an accredited program within 24 months if hired after September 1, 2010, with a goal to obtain a BSN within five years.
- Current RN license in New York State.
- BCLS, ACLS, or PALS certification required.
Additional Salary Details: The listed salary range is a good faith estimate and may be adjusted based on various factors including location, experience, and credentials.