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.
• Prioritizes data collection based on the patient's immediate condition or needs.
• 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.
2. Analyzes patient assessments to determine nursing diagnoses and identifies expected outcomes.
• 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.
• Collaborates with appropriate disciplines and integrates various assessments to formulate an individualized plan of care based on patient needs and current nursing practice standards.
• Reviews and updates the plan of care as the patient condition changes, at least every day.
• Documents the plan of care in the medical record.
4. Implements the interventions identified in the plan of care.
• 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.
5. Evaluates the patient's progress toward attainment of outcomes.
• Performs ongoing and systematic reassessment according to department standard or more frequently based on patient condition.
• Revises nursing diagnoses, outcomes and plan of care based on reassessments.
• Involves the patient, significant others and healthcare team in the evaluation and update of plan of care as appropriate.
• Evaluates the effectiveness of treatments, medications and patient teaching.
6. Performs all other duties as assigned.
1 year Nursing experience preferred.
SPECIAL SKILL, LICENSE AND KNOWLEDGE REQUIREMENTS
Louisiana Nursing License.
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