• Conducts systematic, continuous, and comprehensive assessments of patient health status from admission or encounter to discharge across the care continuum to ensure patient safety, collaborating with the healthcare team, patient and family. Care addresses all aspects of the individual and family, including age, gender, spiritual, cultural, physical, psychosocial, and patient preferences.
• Administers medications per licensure authority, assesses and reassesses the effects of these medications, and documents administration in a timely manner per policies, procedures, and regulatory requirements. Consistently adheres to patient safety guidelines regarding all aspects of medication administration.
• Collaborates with the healthcare team, plans care using current scientific knowledge, theory, and care standards within the nursing interventions and outcomes framework and national patient safety goals. Constructs individualized, age specific plans for optimal patient and family outcomes, as appropriate to the practice setting. Incorporates data from the multi-disciplinary Care Team into the plan of care to assure continuity and appropriate patient teaching.
• Collaborates with healthcare team, identifies and prioritizes patient problems based on subjective and objective assessment data, patient safety considerations, patient and family goals and preferences, and nursing interventions and the medical plan of care.
• Implements nursing care interventions to meet patient and family center health care needs. Evaluates care by performing regular and systematic reviews of patient /family responses to interventions; revises the multi-disciplinary plan of care in collaboration with other care Team members to promote desired outcomes.
• Recognizes care variances and takes steps to prevent or intervene with potential or real adverse events to promote safe care.
• Competently and consistently assesses, conducts, and evaluates the outcomes of patient and family teaching, from admission, or episode of care, to discharge. Teaching reflects sensitivity to age, learning needs and cultural background.
• Tracks and trends sepsis, quality, and patient safety data
• Serves as an advocate for the patient and family, demonstrates respect for their rights, responsibilities, and sensitivity to their preferences.
• Complies with HIPAA privacy and security requirements to maintain confidentiality at all times.
• Proactively uses safety surveillance to prevent adverse outcomes.
• Performs other duties as assigned within the scope of nursing practice.
• Demonstrates competent skills, appropriate clinical judgments and chain of command to promote patient safety and reach planned care goals and outcomes.
• Maintains compliance with all company policies, procedures and standards of conduct.
• Performs other duties as assigned