AHMC Healthcare
Location
Whittier, CA | United States
Job description
Responsibilities
Performance Standard
Assessment:
§ Performs appropriate nursing history and physical upon admission and ongoing basis.
§ Collects and documents patient data.
§ Interviews patients and significant others and completes a history documentation.
§ Documents signs and symptoms that indicate actual and potential problems.
§ Incorporates information in the written assessment from families/significant others and members of the health care team.
§ Assesses safety of the patient care environment.
§ Documents patient/family teaching needs in the patient care plan.
§ In conjunction with the patient and family, develops individual patient care plan.
§ Identifies short and long term goals, including discharge planning consistent with established patient care.
§ Documents patient problems and goals requiring intervention, including teaching needs and discharge planning.
§ Provides continuity of care by communicating the plan of care and diagnostic data through the shift report, in accordance with the unit’s guidelines.
§ Involves family members and other health care team members in the development of the plan of care as able and appropriate.
§ Revises the initial patient care plan to the changing needs of the patient.
Implementation:
§ Provides direct nursing care based on the plan of care and established priorities.
§ Sets priorities and gives nursing care based on the patient’s needs.
§ Implements the medical care plan as delegated.
§ Follows through with care plan established by other health team members (i.e., P.T., O.T., Speech, etc.).
§ Writes patient discharge plan and makes appropriate referrals.
§ Delegates and guides aspects of care to appropriate personnel based on level of acuity and individual patient needs.
§ Coordinates the activities of other disciplines of the health team to implement the individual care plan.
Evaluation:
§ Evaluates and documents the patient/family response to nursing interventions related to the stated goals and the overall effectiveness of the care plan.
§ Revises plan of care based on evaluation.
§ Documents the response of the patient to the medical care plan.
§ Documents the response of the patient to nursing interventions.
§ Recognizes alterations in physiological and psychosocial status.
§ Collaborates with other members of health care team to revise the patient care plan according to changing needs of the patient.
§ Documents revision of the goals and plan of care to meet the changing needs of the patient.
Customer Service
§ Consistently strives to implement the unit’s customer service standards and to exceed the expectations and satisfaction levels of patients, families, physicians and other customers.
§ As observed, all interactions are conducted in a professional manner; is supportive and consistently demonstrates the Target 100 standards.
§ Unit surveys consistently meet or exceed hospital benchmark.
§ Verbal and written feedback from patients, family members/significant others, medical staff, visitors and co-workers indicates behavior conducive to positive guest relations.
§ Consistently exhibits appropriate phone protocol (e.g., answers phone promptly, is courteous and helpful).
§ Interacts with other departments for problem resolution and quality patient care.
§ Maintains a quiet, therapeutic environment in the immediate patient care areas, including at the nursing station.
§ Makes rounds to assigned patients; anticipates patients’ needs and answers/responds to the patients’ call lights or paging promptly.
Performance Improvement
§ Serves as a role model in implementing the PDCA (Plan, Do, Check, Act) methodology.
§ Consistently works to improve identified unit-specific problems.
§ Consistently works to improve identified hospital-wide system problems.
§ Uses established systems to document occurrences.
§ Employee has the willingness and ability to perform additional duties and responsibilities in different areas of the unit on an as-needed basis or as determined by management.
§ Follows attendance and all other established hospital and department policies.
§ Demonstrates the philosophy of the team concept.
§ Participates in staff meetings with suggestions that enhance the work environment and increase productivity.
§ Communicates well with supervisor, reporting problems with equipment, supplies or procedures.
§ Requests assistance as appropriate.
§ Complies with all safety and infection control standards.
§ Maintains confidentiality as related to job responsibilities.
§ Exhibits willingness to resolve problems as they arise.
§ Consistently projects positive professional image through appearance and behavior.
§ Attends 75% of staff meetings or reads and initials minutes.
§ Completes assigned work within shift.
§ Complies with time and attendance policy (i.e., KRONOS).
Professional growth and development
§ Completes Annual Updates and Ethics Training within established time frames.
§ Completes general and departmental orientation within established time frames.
§ Attends 80% of unit staff meetings and inservice programs.
§ Maintains licensure/certification as appropriate.
Qualifications:
B. Minimum Experience: One year acute care RN experience preferred.
C. Required Certification/Registration: Current California R.N. license, BLS and PALS required.
Job tags
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