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LTACMinimum Qualifications Current Georgia RN
6 months of medical-surgical nursing experience
Able to team lead in an interdisciplinary team setting
Experienced with providing acute care to inpatient population
Assesses patients through history, physical exam
1.Performs a physical/psychosocial assessment on assigned patients. Accurately recognizes patient problems and/or complications utilizing effective assessment skills. (This is performed on admission and updated each shift.) Completes dietary and functional screening within 24 hours of admission. Notifies dietitian of consult if needed. Reports findings to necessary support staff.
2.Gathers and incorporates all information necessary from all available sources to properly evaluate patient.
3.Always documents initial assessments on the patient admission profile and subsequent assessments in the progress notes in the CPSI System. Documents in a clear, complete and concise manner utilizing the electronic record (CPSI).
4.Following hospital policy and procedures, consistently completes a nursing assessment upon patient admission to serve as a guide for the nursing care plan (within 8 hours).
5.Participates in discharge planning from time of admission to plan for patient needs.
Develops individualized nursing care plans.
1.Accurately formulates nursing diagnosis based on assessment data and develops plan of care within 8 hours of admission.
2.Communicates assessment data and findings with other members of the patient care team. Actively participates in team conference.
3.Conducts patient assessments within 24 hours of admission.
4.Provides age appropriate care to patients.
5.Identifies needs for restraints. Monitors patient while in restraints. Identifies alternative to restraints and documents. On admission obtains consent for restraint use (patient/family). Ensures daily physician order is written. (N/A for IRF)
6.Utilizes low beds and chair/bed alarms to ensure patients are free from falls (IRF).
Monitors and ensures quality patient care.
1.Demonstrates knowledge of Omnicell System and at end of shift reconciles reports.
2.Completes patient care assignments timely, while maintaining quality standards.
3.Regularly reviews work to ensure that all treatments, medications and diagnostic tests ordered by the physician are quickly carried out properly and recorded.
4.Supervises work of LPN’s and HST’s to ensure that patients’ care is high quality and that all other assignments are completed.
5.Performs blood glucose monitoring according to plan of care and policy. Maintains AccuChek machine controls. Meets yearly AccuChek training updates.
6.Holds self and team members to ethical standards.
7.Follows up on patient complaints to resolve issues. Communicates to Charge Nurse/Nurse Manager as needed.
Documents and maintains records and charts.
1.Documents and communicates patient responses and the effectiveness of nursing interventions according to established policy.
2.Effectively implements physicians’ orders. Consults appropriate sources regarding unfamiliar or questionable orders to assure there are no misunderstandings. Signs off orders with date/time by verifying they have been entered correctly into computer. Documents “repeat and verify” on all verbal orders received.
3.Ensures that staff follows accurate and complete documentation procedures according to policy.
4.Ensures that no medical record is on the 30-day delinquent list for assigned patients.
5.Completes action notice forms daily during shift when medication discrepancies occur.
Provides nursing care in cooperation with physician
1.Evaluates the effectiveness and quality of care provided to assigned patients on the unit on a continuous basis. Recommends modifications and improvements in collaboration with the treatment team.
2.Adheres to established medical procedures and precautions when administering (or supervising the administration of) medications, procedures, and diagnostic tests. Utilizes med scanning of patient armband for medication administration.
3.Assures all patients of a safe, sanitary, and therapeutic environment.
4.Makes rounds, either with physicians or independently. Reassesses patients as needed and adjusts interventions to meet needs.
5.Responds effectively in medical emergencies.
Communicate with other department personnel to coordinate efforts.
1.Ensures adequate unit supplies are present for oncoming shift. Ensures that daily cleaning assignments are completed on the unit.
2.Inspects the unit on a daily basis for proper equipment and ensures that all equipment necessary for patient care is in proper working condition. Decreases clutter on the unit by ensuring cleaning assignments are done on assigned shift.
3.Ensures a safe, clean, attractive environment for patient, staff and visitors on an on-going basis. For example, makes rounds and reports any problems such as a safety hazard, e.g., broken furniture; or may rearrange disordered furniture.
4.Assesses the physical condition of the unit equipment on a regular basis. Reports needed repairs or alterations to the appropriate hospital personnel on a timely basis. Removes broken equipment from use to maintain safety of staff and patients.
5.Assesses the status of the infection control program of the unit on a regular basis, and reports deficits to the appropriate personnel.
6.Maintains hand hygiene and enforces handwashing in others.
Instructs patients and family members regarding treatments
1.Consults and works with the interdisciplinary team to develop effective discharge plans utilizing available resources. Drafts discharge summary.
2.Assesses the patients’ needs for teaching and home health care. Identifies home health care needs or options for alternative placement and support resources. Initiates procedures for referral health agencies according to policy.
3.Reviews patient and family knowledge of disease, illness and readiness to accept care for patient at home.
4.Explains prescribed procedures and treatments to gain patient’s cooperation, allay apprehension and promote compliance.
5.Provides education to patients and/or families and provides information weekly. Ensures assigned patients have 100% teaching needs met by discharge.
6.Develops a teaching/discharge plan for individual patients. Uses assessment data as the basis for planning and includes the patient and family in the development of the teaching/discharge plan whenever possible and appropriate.
7.Properly schedules and coordinates routine and special laboratory tests and x-rays, physical examinations. Reviews reports and follows up as appropriate.
Maintains knowledge of current trends in profession
1.Attends internal and external educational programs and professional meetings as available for continuing professional education.
2.Attends regular meetings of available and applicable professional organizations.
3.Reads and evaluates professional literature on continual basis, translates complex or technical information into a format that can be understood by others.
4.Incorporates knowledge of pertinent new trends and developments into section policies and procedures.
5.Attends and participates in department and unit meetings, as scheduled.
6.Is responsible for all functional competencies required.
7.Current American Heart CPR. Attends ARW.
8.Attends mandatory departmental training as required.
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