Labor and Delivery Nurse, ER, MedSurg

Labor and Delivery Nurse, ER, MedSurg

1. Assesses patient physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs. Reviews patient history and physical with patient/family and assures completion within appropriate timeframe. Reviews available information obtained by other health care team members. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and as outlined in policy.

2. Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care. Goals for patient are realistic, measurable and developed in conjunction with the patient/family. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient in the plan of care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patient’s status.

3. Implements the plan of care through direct patient care, coordination, delegation and supervision of the activities of the health care team. Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements. Delegates appropriately, and provides nursing supervision in the provision of care to patients by other licensed nurses and other personnel. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.

4. Evaluates the patient's and family's response to care and teaching, and revises the plan of care as needed. Evaluates patient progress towards goals and expected outcomes in collaboration with other health care team members. Evaluates patient's response and the effectiveness of patient teaching.

5. Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy. Documentation reflects objective/subjective data, nursing interventions and patient’s response to treatment. Regularly monitors task list and attend to physician orders promptly. Documentation is accurate and thorough to provide record of care, provide reasoning and justification for treatments and charges, and meets all regulatory requirements including Meaningful Use and other quality measures. All charges are checked for accuracy by the end of the shift.

6. Provides care based on the best evidence available and may participate in research activities within clinical practice. Participates in unit or facility shared leadership. Interacts and participates in the education, role development, and orientation of facility personnel, patients, students, families and visitors. Promotes/supports growth of others through precepting and mentoring when appropriate and/or when directed.

7. Contributes to society through activities that lead to excellent patient outcomes through timely, effective, efficient, equitable, and safe care. Actively participates in the improvement of national nursing quality indicators and outcomes. Such activities may include participating in professional organizations.

8. RN’s serve as a shift leader and supervise the daily work flow of the department. In such leadership roles, the nurse will monitor her staff holding them accountable for following facility policies, maintaining professional respect and teamwork among the shift, and address any staff and patient concerns during the shift. The charge nurse will provide for immediate response to the situation and will report any incidents to the Director of Nursing on the next normal business hours. All interactions are to be with a positive, friendly, respectful and professional tone, speech and body language.

9. Attends to non-patient care responsibilities of nursing staff including but not limited to:
-attending all mandatory meetings
-completes competencies and other assigned duties monthly (such as cleaning duties)
-completes required task list, documentation and completion of charges.