| 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 practices. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Provides compassionate and family centered care for Urgent Care Center (UCC) patients. Practices under the supervision of the Nursing Manager/Director. | Job Specific Duties | - Communicates patient's progress including critical findings & changes in condition with physician and/or disciplines involved in the care of the child. Performs and documents discharge instructions.
- Completes intakes to prepare patient to be seen by the medical team including vital signs, weight, height, symptoms, and history.
- Delegates nursing care based on knowledge of staff qualifications and competency.
- Performs intake assessment on patients with an emergency condition.
- Performs nursing treatments and follows physician team orders for medication administration, IV hydration, aerosol respiratory support, etc. on assigned patients.
- Plans, coordinates, and implements a transfer to a higher level of care for EMTALA transfers.
- Obtains parental immunization consent for every immunization administered per policy.
- Assists Physician in procedures (I&D, lacerations, sutures removal) as needed.
- Follows physician’s orders, checks labs, tests, and administers patient medications when needed. Adheres to six rights of medication administration per Medication administration policy.
- Assesses IV sites after removal of IV to check for infiltration and redness.
- Ensures safe analgesics/narcotics administration, monitoring and reassessment as per hospital Pain Management policy and procedure.
- Asses electronic health record independently according to hospital policy and completes accurate and timely documentation within 24 hours in the patient’s electronic health record.
- Communicates with patients and families to review plan of care and solicits input. Communicates any patient and family concerns to physician.
- Provides education and documents patient/family teachings on health related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care, etc.).
- Promotes a safe "error free" working environment by consistently performing thorough hand-offs (utilizing SBAR) and infection prevention measures.
- Ensures safe/effective/efficient care delivery with emphasis on absence of medication errors & blood borne infections, avoidance of falls from surface, ouch-free procedural pain, & reduction of pain.
- Completes chart reviews observe for Accreditation and Regulatory Compliance.
- Completes charges on all assigned patients.
- Demonstrates proper personal protective equipment (PPE) indication and use.
- Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH, & ACHA.
- Provides continuous supervision, observation of behavioral health patients, and adheres to non-violent crisis intervention strategies (CPI).
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