UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Applies to:
WW
SMH
RNPH
OR
ED
Amb
Licensed Clinical Position
Job Description
Performance Evaluation
Period Covered by this Performance Evaluation: _____________ TO _______________
Employee Name:
Department/Unit:
Supervisor Name:
Supervisor Title:
Current Title:
CN I, II, III
Approved Title (for reclassifications
only):
Methods of Measurement Include the Following:
Direct Observation
Feedback from staff or patients
Current Title Code:
Approved Title Code (for
reclassifications only):
AGES SERVED
Documentation
PI Reports
Neonates (< 30 days)
Infants (> 30 days and < 1 year)
Pediatrics (> = 1 year & < 13 years)
Adolescents (> = 13 years & 18 years)
Adults (> = 18 years to < 65 years)
Geriatric (> = 65 years)
Not Applicable
Place an “X” if over 20% of work is exposed to one or more of the following conditions:
Confined area
Exposed to weather
Noise Exposure
Vibrations
Extreme temperatures
Atmospheric conditions
Potential allergenic/irritant conditions
Other (specify)
Please check all that apply (Competencies must be up-to-date at time of Performance Evaluation)
COMPETENCIES:
INITIAL:
RR UCLA Medical Center Dept. Specific Orientation
ANNUAL:
Department of Nursing
Department of Nursing and Service
Unit (Float excluded)
Unit (Float excluded)
SUMMARY STATEMENT:
The staff RN is a professional caregiver who assumes responsibility and accountability for a group of patients for a designated time frame and
provides care to these patients via the nursing process and other input from healthcare team members.
TYPE OF SUPERVISION RECEIVED:
Under direct supervision of the Unit Director and Clinical Nurse Specialist-Supervisor, the primary responsibilities of the clinical nurse include the
direct nursing care of patients utilizing the nursing process; development and application of leadership, management, and communication
concepts; teaching of patients and staff; maintenance of professional standards.
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 1
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
D
Rating
M
N/A
PATIENT CARE
1. Assessment/Reassessment
1.1
Completes and documents an age appropriate admission assessment within 24 hours of admission
1.2 Collects patient data by interview, review of current/prior medical records, diagnostic test results and collaboration with the
healthcare team
1.2.1. Assesses and documents patient’s cultural, psychosocial, psychological, and physiological status
1.2.2. Assesses and documents patient’s need for dietary, functional, social work, discharge planning, and / or other healthcare
provider referrals on admission. Initiates required referrals through appropriate channels and documents referrals made
1.2.3. Analyzes assessment data and identifies actual and potential patient problems to be addressed during this hospitalization
1.3.
Recognizes and documents abnormal assessment findings or significant changes in patient’s condition
1.4.
Reassesses assigned patients at the beginning of the shift and at specified intervals throughout the shift and when the patient
condition warrants reassessment and documents findings
1.5.
*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently focus on the most
significant patient problems
1.6.
*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to identify and document
subtle changes in the patient’s condition
2. Plan of Care
2.1
2.2
2.3
D-
On admission:
Involves the patient/family/significant other in the development and documentation of relevant, measurable patient goals from the
patient problems identified during the admission assessment
Incorporates and documents the patient's advance directive in the plan of care
Recognizes, incorporates and documents patient individuality, culture, ethnicity, spiritual beliefs, gender, race, age, disability,
lifestyle and values into the plan of care
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 2
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
D
2.4
Selects and documents appropriate standards/guidelines in the plan of care to meet patient goals
2.5
2.6
Incorporates the treatment goals of the healthcare team into the patient’s plan of care
Communicates patient’s goals/care plan during inter-shift report
2.7
2.8
Rating
M
N/A
*Develops and documents plan of care for complex patient care problems involving multiple resources
*Utilizes experience and in-depth knowledge to effectively modify and document changes in nursing care and/or the
plan of care to address complex patient care problems
2.9
*Mentors CN I, CN II in developing and documenting patient goals/care plan
3. Interventions
3.1
Utilizes communication strategies and behaviors that convey compassion and caring
3.2
Utilizes communication points identified by the organization to send a consistent
message to improve the patient and family experience
Establishes priorities according to patient care needs and unit resources
Provides, directs and documents age appropriate care to patients based on:
3.3
3.4
3.4.1. the plan of care and medical orders
3.4.2 patient preferences and
3.4.3 consideration of cultural, psychosocial, psychological and physiological factors
3.6
Demonstrates critical thinking, a global grasp of the patient’s condition, and an
integration of formal and experiential knowledge in clinical decision making
Ensures basic patient hygiene needs are met and documented
3.7
Ensures patient safety by following hospital policies with focus on:
3.5
3.7.1
Accurate patient identification
3.7.2
Administration and documentation of medications
3.7.3
Administration and documentation of blood products
3.7.4
D-
Prevention and documentation of patient injury and falls, and
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 3
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
3.7.5
D
Rating
M
N/A
Use and documentation of restraints
3.8 As a patient advocate:
3.8.1
Assists patients and families in coping with difficulties associated with their illness and hospitalization
3.8.2
Acts with a sense of urgency to meet patient care needs
3.8.3
Identifies and corrects unsafe patient care practices and notifies risk management
3.8.4
Identifies ethical issues and participates in their resolution
3.8.5
Ensures that effective pain management interventions are implemented and documented to obtain adequate relief for
patients’ pain
Collaborates with the healthcare team throughout the patient’s hospitalization to address patient’s spiritual, cultural,
psychological, psychosocial, physical and emotional needs and documents interventions
Utilizes the appropriate chain of command to address abnormal and significant changes in the patient’s condition or an
unmet patient / family concern/need and documents actions taken to advocate for the patient
Initiates and documents appropriate interventions in predictable, unpredictable, pre-emergent and emergent patient care
situations
3.8.6
3.8.7
3.8.8
3.8.9
3.8.10
3.8.11
*Collaborates with medical staff in managing pre-emergent and emergent patient care situations
*Collaborates and coordinates with healthcare providers in managing complex patient problems
*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently implement
and document nursing care interventions that address complex patient care problems
4. Evaluation
4.1 Evaluates and documents patient's responses to nursing interventions
4.2 Evaluates and documents patient's progress towards goals
4.3 Modifies and documents nursing interventions and patients’ goals / plan of care as needed
4.4
*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently focus, modify and
document nursing care interventions and/or the plan of care to address complex patient care problems
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 4
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
4.5
D
Rating
M
N/A
*Proposes alternative interventions for complex patient care problems to CN I and CN II
5. Patient, Family and Staff Education
5.1 Patient and Family Education
5.1.1
5.1.2
5.1.3
5.1.4
5.1.5
Identifies and documents patient/family/significant other’s educational needs and readiness to learn
Provides and documents age appropriate healthcare teaching
Evaluates and documents patient/family/significant other’s response to healthcare teaching and/or performance of return
demonstration
*Provides and documents age appropriate individualized teaching for complex healthcare educational needs
*Assists the Clinical Nurse Specialists/designee to identify healthcare education needs
5.2 Staff Education
5.2.1
5.2.2
Orients float, traveler and / or registry staff to unit operations, policies, procedures, evidence based practice protocols and
standards (omit for CNIs)
Teaches staff and / or students(omit for CNIs)
5.2.3
Precepts and mentors staff members(if applicable)
5.2.4
5.2.5
6.
*Assists in identifying staff members' learning needs
*Shares in-depth knowledge with other staff members
Leadership/Teamwork
6.1
Delegates and supervises completion of appropriate tasks to licensed vocational nurses and unlicensed assistive personnel
6.2
Admits, transfers and discharges patients as directed by charge nurse
6.3
Acts as a resource(including students)
6.4
Uses effective, respectful communication, interpersonal, and problem-solving skills to achieve desired patient outcomes and unit
goals
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 5
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
D
6.5
Engages in ongoing development of clinical knowledge
6.6
Keeps informed of clinical / unit / organizational updates / changes
6.7
Adheres to department attendance standards
6.8
Complies with employment requirements, for example annual unit / department competencies, licensure, CPR & TB
6.9
6.10
Rating
M
N/A
*Acts as an clinical leader by directing proficient clinical care on their assigned unit
*Questions and evaluates current practice, promotes evidence based practice to achieve best patient outcomes
6.11 Assumes charge responsibilities as needed:
D-
6.11.1
Provides supervision to nursing staff, unlicensed assistive personnel and supplemental staff
6.11.2
6.11.3
Makes staffing decisions for current and oncoming shifts using the staffing matrix as a guide and approves overtime as
required to maintain safe patient care
Makes patient care assignments based on staff competencies, patient acuities, and available resources
6.11.4
Coordinates and facilitates flow of patient admissions, transfers and discharges with bed control
6.11.5
Ensures completion of required unit routines including, narcotic count, ER cart checklist and other unit specific tasks
6.11.6
Requires ill / injured staff to have medical evaluation and complete required forms
6.11.7
Interprets policy, procedures and standards and assists compliance by staff
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 6
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
D
Rating
M
N/A
UCLA C-I-CARE/Patient Experience Practices: MY COMMITMENT TO CARE
 Observe and practice all the Service Standards listed in the “World Class Practices” (which I have read and signed)
o Practice C-I-CARE when interacting with patients, their families, visitors, or internal customers
o Connect with the patient and family members by addressing them as Mr./Ms., or by the name that they prefer
o Introduce yourself and your role
o Communicate what you are going to do, how long it is going to take, and how it will impact the patient.
o Ask and anticipate patient and/or family needs, questions or concerns
o Respond to patient and/or family questions and requests with immediacy
o Exit courteously and/or with an explanation of what will come next (or when you will be back to check on them)
o Practice C-I-CARE phone etiquette during all phone interactions
 Always exercise courtesy whenever patients, family members, visitors and co-workers are present
o Respect privacy and dignity of our patients, family members, visitors and co-workers
o Maintain professionalism in the presence of patients, their families, visitors and co-workers
 Observe departmental Patient Experience plan, competencies and practices
o Act as a role model, verbally and behaviorally demonstrating skill, enthusiasm, positive problem solving, commitment and
loyalty to the profession and the organization
o Participate in positive problem solving by providing suggestions and possible solutions to identified concerns/problems in
the work place

Comply with Health System Workplace Conduct Policy
o Engaging in disruptive behaviors that interfere with or prevent normal work functions or compromise patient safety,
including passive or active behaviors will not be tolerated as stated in the HS Workplace Conduct Policy

Comply with Health System Dress Code Policy and practices
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 7
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Duties and Tasks
D
Rating
M
N/A
INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS
 Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job
 Comply with Department of Public Health (DPH), The Joint Commission and other accreditation and regulatory agencies standards
 Adhere to all Hospital Policies and Procedures
 Knowledge and adherence to Infection Control and Environment of Care Guidelines and Procedures as described in the annual
education module
PERFORMANCE IMPROVEMENT
 Adhere to current organizational Performance Improvement priorities
 Participate in quality studies through data collection and dashboard data collection
 Make recommendations and take actions to improve structure, system or outcomes
OTHER DUTIES
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 8
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
Skills, Knowledge and Abilities
(Disregard this section for performance evaluations)
REQUIREMENTS:
List any equipment (machines, tools, office appliances or motor vehicles) required to do the job, with or without a reasonable
accommodation. Indicate whether use is seldom, occasional, frequent, or constant.
CPR:
License:
RN
See Policy/Procedure Equipment Manual
Certifications:
Degree:
Experience:
Skills, Knowledge and Abilities:
Importance
(Required or Preferred)
Ability to complete a Nursing physical assessment
Skill in developing a plan of care including setting goals, monitoring and documenting progress
Ability to implement interventions that are pertinent to goals established in the plan of care
Ability to evaluate the effective of interventions toward the attainment of established goals and to recognize the
need to reassess or reset goal parameters
Ability to delegate tasks in a management style that is consistent with promoting leadership and teamwork
Knowledge base to provide education to patients, families, and other staff regarding clinical and patient care
issues
Required
Required
Required
Required
Required
Required
Required
California Registered Nursing License/or CA IPRN
Required
Cardiopulmonary Resuscitation Certification
IPRN:
CNI:
CNII:
CNIII:
D-
Active CA IPRN License
Less then 6 months nursing experience
Greater than 6 months nursing experience
Greater than 6 months recent clinical nursing experience on the unit and meets CNIII criteria
Does Not Meet Expectations
M-
Meets Expectations
N/A
Required
Required
Required
*
CN III Requirement
Page 9
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.
UCLA Health System
UCLA Health System
JOB DESCRIPTION/PERFORMANCE EVALUATION
If overall rating is “Does Not Meet Expectations”, please complete Future Plans and Actions Section.
According to the Employee Performance Evaluation Policy, an overall rating of “Does Not Meet Expectations” requires an action plan and a follow-up
performance evaluation in either a three-month or six-month period depending on the time needed to demonstrate improved performance. Action plan
steps must be objective and measurable with a defined time frame. The date of the follow-up performance evaluation will reset the performance
evaluation due date.
Does Not Meet Expectations
Meets Expectations
Comments:
Future Plans and Actions:
Accomplishments / Contributions:
Employee Comments:
To update our files, please answer the following questions:
Have you received a higher education degree in past 12 months:
Yes______No______
If Yes, in what field:_______________________________________
Type:_____________
Have you received a national certification in the past 12 months:
Yes______No______
If yes, please list and bring a copy of certificate to Nursing Resources:__________________
Employee Signature
I have reviewed this Job Description and/or Performance Evaluation
Date
Evaluator Signature
Date
Department Head or Designee Signature
Date
D-
Does Not Meet Expectations
M-
Meets Expectations
N/A
*
CN III Requirement
Page 10
Directions:
You have the option of checking the large boxes next to the headings or of checking the small boxes to indicate performance for each criteria.