Job Description

JOB PURPOSE OR MISSION:

To improve the quality of life of patients and families by coordinating patient care processes of assessment, planning, implementation and evaluation in collaboration with the patient, family, physician, and appropriate support services for the age population served, as defined in the department's scope of service.

ESSENTIAL JOB FUNCTIONS include, but are not limited to:

1.

Coordinates patient assessment through collection of patient's health data.

PERFORMANCE STANDARDS:


Prioritizes data collection based on the patient's immediate condition or needs according to procedure/surgery scheduled. Performs ongoing and systematic comprehensive physical and psychosocial assessments. Involves the patient, significant others and health care providers as appropriate. Performs functional, nutritional and other screenings and ensures triggers are complete. Identifies and coordinates the need for further assessment by discipline. Documents patient care assessments in the medical record. Documents outpatient Admit Database in EMR

2.

Analyzes patient assessments to determine nursing diagnoses and identifies expected outcomes.

PERFORMANCE STANDARDS:


Determines nursing diagnoses using assessment data. Identifies patient outcomes based on the nursing diagnoses. Outcomes are prioritized based on the patent's condition and needs. Nursing diagnoses and outcomes are documented in the medical record. Triage assessment on all patients and follows protocols according to established department guidelines and policies. Demonstrates ability to proficiently assess patients in every age group.

3.

Coordinates an interdisciplinary plan of care that prescribes interventions to attain expected outcomes.

PERFORMANCE STANDARDS:


Collaborates with appropriate disciplines and integrates various assessments to formulate an individualized plan of care based on patient needs and current nursing practice standards.

4.

Implements the interventions identified in the plan of care.

PERFORMANCE STANDARDS:


Collaborates with the interdisciplinary health care team to deliver direct patient care utilizing nursing practice standards, and universal blood and body fluid precautions. Uses interventions that are consistent with the patient's plan of care. Maintains patient rights. Ensures that patients receive the appropriate treatments and medications in a timely manner. Delegates patient care to other members of the health care team; ensures the delegated task(s) are within the scope of practice of the assigned individual and maintains oversight and accountability. Coordinates direct patient care from appropriate support services. Provides individualized patient education to patient and families. Collaborates with the interdisciplinary team to plan patient discharge. Documents all treatments, medications, patient/family education and ongoing assessments.

6

7.

Performs other duties as assigned.

EXPERIENCE REQUIREMENTS

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1 year Nursing experience preferred

EDUCATIONAL REQUIREMENTS

Current BLS Healthcare Provider

SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENTS

Current Louisiana RN licensure

Demonstrated competency in patient assessment, venipuncture, phlebotomy, and ASA classification.

HIPAA REQUIREMENTS:

Maintains knowledge of and adherence to all applicable HIPAA regulations appropriate to Job Position including but not limited to: Medical records wihout limitation both paper and electronic, patient demographics, lab and radiology results, patient information related to surgery or appointment schedules, medical records related to quality data, patient financial information, patient billing 3rd party, patient related complaints, information related to patient location, and/or patients' religious beliefs.

SAFETY REQUIREMENTS:

Maintains knowledge of and adherence to all applicable safety practices appropriate to Job Position including but not limited to: Incident reporting, handling of wastes, sharps and linen, PPE, exposure control plans, hand washing, environment of care, patient identification, administers medications and blood products, receives orders for patients, validates patients for any procedure/surgery, transports, monitors or observes patients with infusion pumps, monitors clinical alarms, and collects blood samples.