Job Description

PRINCIPAL FUNCTION:

Provides nursing care to assigned patients utilizing the Nursing process to assess, plan, implement and evaluate patient service needs based upon a physician's plan of treatment. Coordinates care delivered by other health disciplines for assigned patients.

RESPONSIBILITIES:

A. Assessment

1. Obtains medical history, conducts body systems assessment and assesses psychosocial status for each assigned patient upon admission.

B. Planning

1. Develops nursing diagnostic problem list for each patient. Updates list, as necessary.
2. Develops nursing care plan for each assigned patient who includes elements of plan of treatment and discharge planning.
3. Collaborates with other health disciplines in development of care plan, as indicated.

C. Implementation

1. Provides direct patient care with clinical competence according to the plan of treatment, nursing care plan and established standards.
2. Initiates preventative and rehabilitation nursing procedures as planned for patient's care and safety.
3. Observes and monitors patient's status and progress toward planned outcomes including discharge plans.
4. Teaches patient and family regarding reporting of signs and symptoms to nurse and physician.
5. Coordinates and supervises care delivery and patient status related to other health care disciplines.

D. Evaluation

1. Evaluates assigned patients progress toward achievement of goals and planned outcomes.
2. Updates nursing care plan as goals are achieved or when new patient care problems occur.
3. Evaluates effectiveness of patient/family teaching and learning.
4. Reports patients' progress and changes in the patient's condition to the physician. Obtains and implements new orders when indicated.

E. Professional Conduct

1. Documents nursing process, patient's response to care, patient status and progress toward goal attainment completely and accurately.
2. Submits required documentation in a timely manner.
3. Maintains confidentiality of all matters related to patient care and Agency business and in accordance with all HIPAA guidelines.
4. Participates in patient care conferences and in-service programs.
5. Reports to assignments punctually and per schedule. Gives proper notice of absenteeism or tardiness.
6. Works cooperatively and communicates effectively with all members of the health care team.
7. Participates in educational opportunities to increase, clinical knowledge and competence in practice.
8. Treats all employees and clients with value, dignity and respect.
9. Performs other duties appropriate to education or experience, as assigned.
10. Complies with Agency Code of Conduct.

QUALIFICATIONS

1. Registered Professional Nurse licensed in State of Illinois or Iowa or other appropriate state in accordance with assignment.
2. Minimum of one-year nursing experience in a hospital.
3. Demonstrates good assessment skills with ability to work with minimal supervision.

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