Registered Nurse Resident

Essential Function

Provides nursing care according to medical regimen and the nursing interventions appropriate for the patients' conditions and according to established standards, policies and procedures including care of the ambulatory practice patient.

Initiates assessment based on the patient's presenting problems or needs, the physician's medical diagnosis and the functional health framework upon visit. Collects key information from patient, family, laboratory, and other medical reports. Ensures that all consents necessary for treatment/procedure have been signed and that all prescribed identification procedures have been carried out.

Determines nursing diagnosis and priorities for care with special consideration given to patient teaching, discharge planning, and the growth and development needs of the patient. Determines which standards of care and practice apply to the patient. Documents assessment, including nursing diagnoses or other clinical judgments.

Demonstrates knowledge, technical, interpersonal and critical thinking skills to provide care, manage clinical competency and meet age-specific patient needs within the unit.

Completes ongoing assessments according to outpatient and nursing policy and/or as determined by patient condition: re-prioritizes care based on new information, continues to update nursing diagnoses, and involves family and/or other significant individuals in assessment activities.

Assesses, plans and implements care of assigned patients. Performs therapeutic nursing interventions: as ordered by the Physician consistent with primary and population-specific standards of care and practice with consideration given to knowledge gained from the initial and ongoing assessment of the patient consistent with nursing division policies and procedures, demonstrated competencies, and with consideration given to risk management, infection control practices and patient safety practices

Essential Function consistent with the nature of the unit

completion of history and physical assessment administration of medication, treatments and immunizations prepares patient for examination/procedures; positions and drapes patients pain control interventions provides assistance during examination/procedures monitors patient responses during treatment/procedure (checks temperature, pulse, blood pressure and respiration) initiates corrective action whenever information from monitoring or life support equipment shows adverse symptomatology such as respiratory or cardiac insufficiency coordinate patient referrals patient education Documents care based on standards of care and practice and/or clinical priorities for documentation including: assessment and ongoing assessment findings updated clinical priorities for documentation therapeutic nursing interventions with special attention to patient education patient's response to interventions and progress towards outcomes are noted

Responds and/or participates with medical emergencies. Initiates and/or assists with CPR/BLS as required.

Provides teaching to patient/family in the care of disease/condition. Develops and implements patient teaching outlines including objectives, content, teaching strategies and evaluation of patient progress.

Maintains patient medical records; documents patient status and care given; performs charting duties; records activities and observations. Utilizes patient computer systems to enter and retrieve data.

Confers and works collaboratively with patient/family/hospital staff regarding all aspects of patient needs in a customer responsive and courteous manner, in compliance with iRESPECT Standards and promoting patient/customer satisfaction.

Maintains a position in hiring unit, in good standing for at least 1 year after the beginning of residency. After the first year, may transfer within the facility.

Transports monitored patients, specimens, equipment and supplies to and from various areas.

Collaborates with forensic team and security to provide safe environment for patients in custody.

Completes required continuous training and education, including department specific requirements.

Attends staff meetings, all mandatory in-services, and additional continuing education as required. Contributes to the annual review of unit-based scope statement and determination of important aspects of care for clinical review. Assists in the development of indicators, thresholds, study methods, and data collection as assigned. Responds to problems/opportunities to improve care. Supports and is involved in the organization’s performance improvement initiatives. Participates in and maintains competencies required for the position. Completes an Evidenced Based Project within the guidelines of the Nurse Residency program. Attends all monthly Residency education sessions.

Maintains a clean, orderly, safe environment for patients and personnel. Adheres to established policies, compliance/quality improvement, and safety, environment and infection control standards.

Prepares and maintains required records, reports and files for administrative and compliance purposes.

Excellent interpersonal and communication skills.

Physical Demands

A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Physical Demand

N/A

Rarely

Occasionally

Frequently

Constantly

Weight

Standing

X

Walking

X

Sitting

X

Lifting

X

Carrying

X

Pushing

X

Pulling

X

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Handling

X

Grasping

X

Feeling

X

Talking

X

Hearing

X

Repetitive Motions

X

Eye/Hand/Foot Coordination

X