Summary:

Responsible for patient assessment, patient care planning, and provision of quality nursing care to an assigned group of patients for a defined work period. Provides direction and supervision to LVN/LPNs, nursing assistants, unit secretaries, and other clinical/clerical associates. By assignment, may function as a charge nurse for the unit. Involves provision of patient care/service to older adolescents, young adults, adults, geriatric and pediatric patients.

This position is specific to the LDRP and LDRPN Departments.

Responsibilities:

*Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
*Patient Care Planning
*Develops a comprehensive nursing care plan which addresses all significant needs and problems identified through nursing assessment.
*Prepares nursing elements of the interdisciplinary care plan prior to the initial team conference.
*Reviews and updates nursing care plan and collaborates with team members as changes occur.
*Patient Care Provision
*Implements patient care as planned in nursing care plan and interdisciplinary care plan.
*Sets priorities based on knowledge of patient acuity and patient needs.
*Provides safe and therapeutic care and seeks resources when appropriate.
*Safely performs and accurately documents procedures, consistent with established nursing policy and procedure.
*Patient Care Evaluation
*Evaluates patient response to interventions and attainment of goals in collaboration with interdisciplinary team.
*Evaluates progress toward nursing goals and revises goals as needed on a weekly basis.
*Completes nursing progress note for assigned patients on a daily basis.
*Completes nursing flow sheets for assigned patients on a daily basis.
*Teaching
*Evaluates education needs of patient and significant others and documents their response to teaching.
*Utilizes, adapts, and revises teaching resources to meet patient education needs.
*Explains procedures, tests, and disease process to patients and families as needed.
*Acts as role model for health care students and other team members.
*Acts as preceptor to assigned orientees.
*Assists in the orientation of new staff by sharing knowledge and experience.
*Patient Care Communication* Reports and documents accurately and concisely to appropriate persons the patient's condition.
*Maintains patient confidentiality.
*Applies basic verbal and nonverbal skills to maintain open, effective communication among care team members, patients, and significant others.
*Encourages direct discussion between staff members when differences occur and seeks assistance to arbitrate differences as needed.
*Gives and accepts constructive feedback appropriately.
*Identifies actual and potentially unsafe patient care practices, reports them in the designated manner, and suggests alternatives.

CORE COMPETENCIES
Standard I: Utilizes the Nursing Process
*Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
*Spiritual, and development needs of patient and families
*Communicates findings to appropriate healthcare team members
*Develops and uses a specific plan of care and modifies it to meet individual patient
*needs using evidence-based practice. Implements patient care and therapeutic
*procedures; monitors and documents progression of treatment and teaching goals
*Evaluates the care and treatment(s) provided to the patient and the patient response to
*the care and treatment(s). Performs timely reassessment and documentation
*Must be able to perform unit specific competencies based on the specific patient care need for designated unit's patient population

Standard II. Patient Throughput & Patient Flow Process
*Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
*Utilizes appropriate systems of communication and tools to facilitate the discharge process
*Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy

Standard III. Unit Operations
*Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
*Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
*Assesses departmental staffing needs; actively participates in resourcing efforts.
*Educates and trains others on the operations, ethics, and regulations within the industry

Standard IV. Safe Practice/Quality Care/Regulations
*Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
*Demonstrates accountability for nursing research and quality improvement activities
*Provides evidence-based nursing care
*Communicates patient information effectively across the continuum of care
*Educates and trains others on the operations, ethics, and regulations within the industry.
*Knowledge of federal, state and local healthcare related laws and regulations; ability to comply with these in healthcare practices and activities

TECHNICAL COMPETENCIES
Clinical Policies and Standards
*Follows a specific set of standards and associated clinical procedures
*Analyzes policy and standards documentation and ensures organizational compliance
*Provides feedback for improvement of procedures
*Assists in the development and implementation of specific procedures
*Works with control and monitoring mechanisms, tools and techniques

Health Information Documentation
*Shares experiences with maintaining paper and electronic patient documentation
*Walk through the steps and procedures for receiving, validating and updating patient records
*Describes the flow of information between various stations or units
*Discusses the functions, features and document flow of electronic documentation
*Transcribes verbal orders; explains techniques for ensuring their accuracy
*Explains health information documentation best practices and their rationale across health care practices

Medical Equipment
*Describes experience with basic medical equipment used in own unit or facility
*Uses standard diagnostic tools and techniques to resolves common equipment problems
*Educates patients about the appropriate use of home medical equipment
*Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
*Inspects, troubleshoots and evaluates incoming equipment

Medical Order Processing
*Shares experiences with processing medical orders for one or more groups of patients or conditions
*Describes functions and features of the system used to enter, validate, update and forward medical orders
*Discusses common errors, their sources and procedures for correcting
*Explains considerations for entering and following standing orders
*Differentiates between standing orders and preprinted orders and considerations for each

Patient Chart Reading and Interpretation
*Describes experiences in reading and interpreting patient charts for patients on unit and under own care
*Reviews patients' charts for completion and accuracy; identifies and alerts to mistakes or omissions
*Recognizes unexpected readings and alerts nursing or medical staff
*Relates examples of mis-readings or misinterpretations and lessons learned
*Reviews, discusses and validates own interpretation with others

Patient Safety
*Shares experiences with ensuring safety for one or more patient groups or settings
*Explains key features of safety guidelines and procedures for those groups and settings
*Listens and responds to safety inquiries from patients and family members
*Recognizes and addresses physiological and psychological signs of problems
*Describes considerations for patients who can cause to harm to self, versus harm to others
*Utilizes appropriate systems to document misses and near misses, participates in immediate investigating, analysis and reporting in real time

Meets all requirements identified in this position description.

Requirements:

Experience:

• 1 year of experience in the related nursing specialty preferred.
• Perinatal RN Residency, or recently practicing in a Perinatal Setting is preferred.

Education:

• Bachelor of Science Degree in Nursing preferred.
• All newly hired experienced RNs must attend New Nurses Orientation within the first 30 days of hire.
• New hires are precepted by a designated trained staff member and initial on-boarding requirements are validated through successful completion of the designated organizational entry competency validation and a Perinatal Department-specific competency validation.
• Completion of all annual competency verification requirements.

Licenses/Certifications/Registrations:

• RN Licensure in state of employment or compact.
• BLS required.
• Current certification from NCC Electronic Fetal Monitoring (C-EFM) or one of the following AWHONN courses: Intermediate FHM, Intermediate FHM Instructor, Advanced FHM Instructor, or Instructor Trainer at time of hire or prior to the end of orientation for experienced nurses; within 90 days of hire for new graduates and experienced nurses new to the specialty then required to maintain course certification thereafter.

Work Schedule:

7PM - 7AM

Work Type:

Full Time

EEO is the law - click below for more information:

https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12ScreenRdr.pdf

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