Description

 Job Summary:

Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation.  Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights.  Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate and family centered care for Minor Procedure Suite patients.

Minimum Job Requirements:

• RN licensure within the State of Florida in good standing and throughout employment.

• CPR: Healthcare Provider – must maintain active and in good standing throughout employment.

• PALS within two years of hire and in good standing prior to expiration and throughout employment. 

Qualifications

Essential Job Duties:

Nursing Care Functions:

• Supports the Service Recovery Program. Ensures that his/her behavior meets/exceeds acceptable Service scores as measured by the Service Index.

• Completes all nursing multi-system assessments that include head to toe, vitals, pain management, falls risk assessment, post anesthetic scores, and airway management.

• Ensures completion of patient pre-admission/admission history and prepares and accurately completes the discharge planning process accurately as per department and hospital policies and procedures.

• Communicates and documents the patient's progress including critical findings, changes in patient's condition with the physician or disciplines involved in the care of the patient.

• Implements and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.

• Provides nursing care that includes IV site monitoring, specimen collection, and assists surgical team with specific procedures.

• Follows physician's orders, administers and reconstitutes medications when needed. Adheres to six rights of medication administration per medication administration policy.

• Ensures proper and safe sedation administration to patients and monitors recovery as per the PACU Policy and Procedure.

• Cross trained to provide safe patient care in Pre-Op, Intra-Op, PACU 1, and PACU 2.

• Leads turnover between cases with Care Assistants to provide safe and clean environment of care.

• Ensures advanced directives, secures blood consents, documents time-out procedures, and ensures the correct site/side is marked (when applicable per Universal Protocol Policy).

• Greets family and patient, transports patient into OR. Acts as liaison to update family with procedure progress to ensure top tier patient and family satisfaction (SEI index).

• Collaborates with a multi-disciplinary team in daily care planning, as appropriate, and fosters a Family Centered Care Environment.

• Remains with the patient during emergence and extubation and assists Anesthesia team as needed.

• Transports the patient to recovery room and completes the SOAR checklist for the procedure with transition of care performed with a hand-off to the PACU RN.

• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.

• Performs reassessments as per policy and when there is a change in the plan of care or when an intervention is performed.

Charting/Documentation:

• Accesses electronic health record independently according to hospital policy and completes accurate and timely documentation in the patient's electronic health record.

• Communicates and documents critical lab results per hospital policy and procedures.

• Ensures all surgical procedure documentation is obtained (i.e.; labs, consents, advance directives, custody documentation) in a timely and accurate manner.

Patient Family Communication:

• Educates patients and families about the medical procedure, diagnosis, and discharge instructions.

• Communicates with patients and families to review plan of care and solicits input. Communicate any patient and family concerns to physician.

• Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care Environment.

• Provides education and documents on patient/family teachings on health related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care, etc.).

• Communicates and documents critical lab results per hospital policy and procedures.

Quality and Safety:

• Promotes an "error free" working environment by consistently providing high-quality safe care as prompted (as per Universal Protocol Policy).

• Assesses all body systems, ensures safe effective, and efficient care delivery with emphasis on the absence of medication errors, avoidance of falls & reduction of pain post-op.

• Provides patient information and effectively completes the hand off process during patient reassignments as per SOAR document.

• Responsible for proper PPE indication and use.

• Accountable to optimize first case starts to prevent delay of patient care per departmental goals.

• Actively participates in hospital-wide committees and unit based committees on turnover or first case starts and utilizes lean processes.

• Performs skin & structural assessment, takes measures to accommodate patient & ensures safe care while ensuring no medication errors. Performs falls risk assessment & takes appropriate steps.

• Accountable to ensure the proper steps are followed in the processing of Gastro Intestinal scopes per departmental policy/protocol which meets infection control standards.

• Meets or exceeds unit standards in achieving CEI tandards; completes documentation in a timely manner & accountable to regulatory requirements of the DNV, CMS, DOH & other agencies.

• Promotes safety by actively practicing time-out. Documenting all implants and blood transfusion products per the Surgical Services Policy on blood transfusions, implants, and time-out procedures.

Common Duties:

• Maintains accountability to ensure compliance thru timely completion of licensures, certifications, competencies, health requirements (PPD, N95, Flu), initial competencies & education requirements.

• Maintains professional accountability & timekeeping expectations as outlined by policy and complying with attendance guidelines & procedures. Ensures behavior is compliant with standards.

Knowledge/Skills/Abilities:

• BSN degree preferred or currently enrolled in BSN program (requiring proof) within 6 months of hire.

• A minimum of 1 year experience as a RN preferred.

• Career Development: National Certified Pediatric Nurse (CPN) and/or certification equivalent within 5 years of hire preferred.

• Possesses proficiency in computers and EMR preferred.

• Able to analyze and interpret data and utilize the information to make judgments regarding patient care.

• Effective verbal and written communication skills.

• Ability to positively influence, hold self, and others accountable.

• Able to work effectively in collaborative environment.

• Ability to apply principles of evidence-based practice, analytical thinking, and service excellence in practice.

• Able to float within Surgical Services while maintaining the delivery of clinical excellence and high quality service.

• Coverage for on-call assignments per departmental and hospital policy.

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