JOB DESCRIPTION
Department:
Job Title:
Reports To:
Benefit Level:
Med-Surg
Registered Nurse
Director of Nursing
III
Job Code:
EEO Job Family:
FLSA Status:
Creation/Revision Date:
Professionals
Non-Exempt
07/14/2010r, 5/20/14r
Role/Position Definition: Responsible for the provision of nursing care to patients and to
direct licensed and non-licensed staff in the same. Assesses, plans care, provides treatment
regimes, evaluates care and collaborates with the physicians and interdisciplinary care
delivery team to provide comprehensive nursing care. Serves as resource person to licensed
and non-licensed staff, assuming leadership roles and responsibilities, as assigned.
Qualifications/Position Requirements:
A. Education/Experience
a) Graduate of accredited school of nursing required.
b) 3 years of experience as a RN strongly preferred.
c) 1+ years of experience providing care in a hospital setting preferred.
d) Experience in a Medical/Surgical unit setting strongly preferred.
B. Licensure/Certification
a) Current unrestricted RN License from the State of Michigan required.
b) Current Basic Life Support Certification for Healthcare Providers, from the
American Heart Association required.
c) Current ACLS certification strongly preferred.
C. Knowledge, Skills, and Abilities
a) Knowledge of BLS protocols in code situations, medication administration, pain
management, wound care, and performance of patient assessments.
b) Knowledge of medical terminology, human anatomy, and physiology.
c) Requires immediate judgment and response; occasionally in response to disasters
or emergencies, actual events or drills.
d) Requires high-level visual and auditory acuity for timely response and patient care
assessment activities.
e) Requires effective listening and language skills adequate for high-level written and
interpersonal communication.
f) Must possess customer service skills and be able to demonstrate at all times.
g) Must be able to demonstrate leadership skills with necessary.
h) Must be able to answer call lights and multi-task.
i) Ability to measure/record/evaluate vital signs.
j) Ability to move quickly in response to physician and patient needs.
k) Ability to recognize and process confidential and sensitive information
appropriately.
Work Environment:
Definitions: Occasionally = .25 – 2.5 hours/day
Frequently = 2.5 – 5.5 hours/day
Continuously = 5.5 – 8 hours/day
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Sitting – Occasionally.
Standing – Continuously.
Walking – Frequently.
Lifting/Carrying 0-10lbs – Frequently.
Lifting/Carrying 10-20lbs – Occasionally.
Lifting/Carrying 20-50lbs – Occasionally.
Lifting/Carrying 50-100lbs – Rarely
Lifting/Carrying over 100lbs – Rarely
Reach Above – Occasionally.
Bend/Stoop – Occasionally.
Use hands for pushing/pulling – Occasionally.
Use hands for fine manipulation – Frequently.
Travel – May travel to locations throughout the organization - Occasionally.
Public Contact – Interaction with public in person and over phone - Continuously.
Blood/Body Fluid – Exposure to blood/body fluid is possible.
Chemicals – Rare
Computer – Use of computer, typing & viewing - Frequently.
Duties & Responsibilities:
A. Assesses the needs of the patients, including physical, emotional, psychological,
spiritual, and social. Serves as resource and collaborates with the Patient Care
Technician regarding abnormal findings, as requested. Completes admission
assessments, establishes nursing diagnosis and nursing care plans based on
assessment, revises care plans as condition changes.
B. Reviews laboratory test results, diagnostic test results and consult reports and
forwards to physician immediately if abnormal, initiates appropriate nursing
interventions immediately. Documents communication with physician, subsequent
medical orders, nursing interventions and administered treatment.
C. Administers treatments following written physician orders and review of patient’s
condition.
Collaborates with interdisciplinary team in determining appropriate
treatment type, duration and dosage. Operates a variety of equipment and performs a
variety of treatments, including but not limited to, Tube feeding, EKG, Foley catheter
insertion/care, oxygen administration, care of the tracheostomy, wound care, IV
insertion, phlebotomy.
D. Assists patients to optimize independence, including but not limited to, ADL skills,
mobility needs, improving cognition, nutritional intake and bowel and bladder
retraining. Provides direct patient care as needed and assists licensed and nonlicensed staff members as necessary.
E. CPSI Documentation is accurate, consistent and concise supporting assessment of
patients, all treatments given, patient’s response to treatment, and changes in
treatment plans. Documentation is in approved format and on designated tools. All
documentation, both narrative and flow sheets, is completed prior to the end of tour of
duty, including co-signature and review of non-licensed staff documentation.
F. Provides patient education and discharge instructions related to medical and
rehabilitation needs. Documentation reflects all teaching provided and patient/family
understanding and return demonstration of self-care, on designated tools. Refers
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complicated cases to members of interdisciplinary team for further instruction.
Participates as assigned at Team Conferences, communicating patient education and
care needs.
Provides discharge instructions to patient/family. Documents all instructions and
teaching on designated tools. Communicates, with facilities receiving patient upon
transfer from Hospital.
Administers medication as per policy/procedure; oral, rectal, intramuscular, subcutaneous, subdermal, IVPB, IV push, PICC, ocular and otic. Demonstrates
knowledge of medications and interactions, if questions arise demonstrates
appropriate follow through. Appropriately documents medication held, refused or
unavailable, communicating the same to the physician/designee.
Responds quickly and appropriately to emergency situations. Assumes roles during
Code Blue emergency and conducts role without difficulty. Monitors and maintains
necessary equipment and supplies.
Accurately notes and transcribes physician/designee orders into CPSI. Exercises
clinical judgement and discusses/questions orders as applicable, prior to executing.
Transfers all pertinent information to kardex, bedside flow sheets, and in room
communication tools.
Walking rounds done at least every hour on assigned patients.
Serves as resource person to licensed and non-licensed staff. Assumes leadership
roles and responsibilities as assigned, exercising strong clinical judgement in the
delegation of duties based on staff licensure/certification and competency in provision
of duties being assigned.
Demonstrates customer focus. Treats all customers, co-workers and supervisors with
respect. Helps create and maintain a positive work environment. Adheres to and
demonstrates Hospital policies, procedures, guidelines and protocols. Actively
participates in process improvement activities and/or committees to improve care
delivery and unit operations.
Performs all other duties as assigned.
APPROVALS
Human Resources: __________________________________________
Department Head:
_________________________________________
Date: ______________
Date: ______________