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REGISTERED NURSE – MEDICAL/SURGICAL UNIT JOB SUMMARY: A clinically competent, registered, professional nurse who delivers care to patients through the nursing process of assessment, planning, intervention, implementation, and evaluation. Effectively interacts with patients, significant others, and other health team members, while maintaining standards of professional nursing for the age groups served. QUALIFICATIONS AND SKILLS: Licensed to practice in the state of Oklahoma. Ability to communicate effectively, both verbally and in writing. Current CPR card or completion within 30 days of employment. PHYSICAL REQUIREMENTS: Must have strength and stamina for prolonged walking, standing, and dealing with stressful situations. Demonstrates adequate vision or correctable with glasses to read and write. Able to hear, or correctable with hearing devices, and able to talk to converse with others in person and over the phone. Able to hear, see, and feel to accurately assess, monitor, and administer care. Able to frequently lift at least 60 lbs., reach, pull, push, bend, stoop, and kneel. Possess fine motor skills and hand/eye coordination to give care (i.e., insert catheters, start IVs, administer medications, and handle instruments). Able to work in latex-burdened environment. JOB RELATIONSHIPS: Reports to: Unit Charge Nurse, Nurse Manager, and Unit Director. Workers Supervised: RNs, LPNs, Nurse Assistants, Techs, Unit Assistants, and Students. Demonstrates a team approach by working cooperatively with other members of the Med/Surg unit and all members of the health care team. PRINCIPAL JOB RESPONSIBILITIES: Complies with safety and emergency procedures Completes hospital/unit competency program Assesses the condition of patient/family in a timely, consistent, and systematic manner. Documents objective and subjective data according to policy. Initiates nursing assessment, performs orientation to room and unit, notifies physician of admission, and obtains admitting orders within time period designated by unit policy (by end of shift). Analyzes assessment data to determine nursing care needs. Accurately reassesses patients once per shift and when patient condition warrants. Includes information obtained from the family/significant other in the assessment. Utilizes LPNs, NAs, and other health care workers to gather data relevant to assessment of the patient. Documents clearly and concisely initial and ongoing assessment data about the patient/family in the permanent record. Documents interventions, patient/family response, and changes in patient condition per policy. Communicates subjective and objective data about the patient/family with appropriate members of the multi-disciplinary team. Reports change in condition and/or other significant findings to team leader or charge nurse. Formulates care plan within 8 hours of admission and revises it every 24 hours as needed. Initiates care plan for patients cared for by LPNs. Formulates and implements a care plan that is: Outcome oriented A reflection of patient’s actual and potential problems Inclusive of interventions and congruent with the medical plan Measurable Mutually set with patient and family Multidisciplinary Inclusive of a discharge plan Coordinates nursing care designed to promote, restore, and/or maintain optimal outcomes Identifies education needs and provides opportunities for formal and informal teaching to patient and family. Documents teaching activities in the medical record. Provides for discharge planning and documents such in the medical record. The nurse acts as a client advocate. Prioritizes care delivery according to the patient's needs and unit activities. Implements physicians' orders accurately and in a timely manner. Assists with and/or performs procedures in accordance with policy/procedure. Safe practitioner in administration of all medications, IVs, blood, and blood products. Evaluates the effectiveness of nursing care and initiates appropriate interventions. The nurse delivers care in a manner that preserves/protects client autonomy, dignity, and rights. The nurse effectively prescribes, delegates, and coordinates nursing care in his/her department. Demonstrates awareness of the need to create a positive climate for interaction between the patient, family, health team members, and students. Demonstrates effective and accurate verbal and written communication. Communicates clearly and appropriately to co-workers both verbally and in writing. The nurse assigns tasks or delegates care based on the needs of the client and the knowledge and skill of the caregiver. Maximizes productivity by consistently completing assignments including documentation by the end of shift. Completes medical record upon patient dismissal with printed care plan, admission assessment, discharge summary, integrated notes of patient progress, MARs, and patient teaching record. The nurse seeks available resources to help formulate ethical decisions. Serves as team leader as needed. Readily accepts assignments with appropriate training and supervision to other areas, including ambulance transfers. Demonstrates maturity for accountability of job performance. The nurse uses research findings in the development of policies, procedures, and guidelines for client care. Assesses personal learning and development needs. Makes plans to meet those needs. Commits to lifelong learning and professional development. The nurse participates in ongoing educational activities related to the practice setting and scope of care. Includes emphasis on Med/Surg, pediatric, geriatric, and short-term psychiatric patients. Demonstrates additional hours of Continuing Education beyond mandatory requirements. Renews RN license by birth month of renewal year. The nurse practices nursing according to professional practice standards guided by the ANA Code for Nurses. ---------- Disclaimer: This job description is intended to provide a general overview of the responsibilities and requirements of the position. It is not an exhaustive list of all duties, responsibilities, and skills required. The company reserves the right to amend and change responsibilities to meet business and organizational needs as necessary. Equal Employment Opportunity: HireVenture is an equal opportunity employer and values diversity. We do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, gender identity or expression, or any other characteristic protected by applicable law. Confidentiality Notice: This job description and any accompanying attachments are confidential and may contain privileged information intended solely for the use of the individual or entity to whom they are addressed. If you have received this communication in error, please notify the sender immediately and delete the original message. Copyright: This job description is copyrighted by HireVenture. Unauthorized use, reproduction, or distribution of this material is strictly prohibited without the written consent of HireVenture. Note: The information provided in this job description is subject to change without notice. Please refer to the latest version of the job description available on our website for the most up-to-date information. ---------- HireVenture www.hireventure.com Powered by JazzHR