Registered Nurse

Job Summary

Delivers care to clients utilizing the nursing processes of assessment, planning, intervention, implementation, and evaluation: and effectively interacts with clients, families, and other ID team members while maintaining standards of professional nursing.

Tasks, Duties, and Responsibilities

• Utilizes the nursing processes by demonstrating appropriate assessment, planning, implementation, and evaluation of the clients’ care, as evidenced by client/staff observation.
• Assesses the clients’ health care needs; collects and documents the clients’ current health status.
• Makes accurate and ongoing assessment of clients’ status and responds appropriately.
• Sets priorities for nursing action in a logical sequence according to Clients’ needs and Medical Providers’ orders.
• Evaluates and analyzes a given situation and makes decisions within the scope of licensed practice.
• Formulates a plan of care.
• Evaluates and performs ongoing assessment and revises plan of care based on new data, clients’ condition.
• Ensures all clinical activities are carried out in accordance with the Health Care Plan
• Performs evaluation of new and existing clients to determine priority of suitably of treatment and need for modifications.
• Documents accurate, legible ongoing assessment of client status.
• Demonstrates accurate and timely documentation.
• Documents client care, which reflects nursing intervention, client response to care provided, and client needs, problems, capabilities, limitations, and progress toward goals.
• Documentation to include evidence of appropriate client/staff teaching and the understanding of the instructions noted in the client’s chart.
• Maintains up to date information in client’s chart regarding all appointments and procedures.
• Compiles data for periodic assessment of client’s physical condition and evaluation of the effectiveness of health care procedures.
• Documents all communication with MD’s, families, case managers program etc. in client’s chart.
• Notifies and documents changes in client’s condition to all appropriate parties.
• Trains client/staff and others appropriate health information in a timely manner and shares information material, performs direct care utilizing established procedures, policies and standards as evidenced by client/staff feedback.
• Observes and documents clients’ response to pertinent medications.
• Demonstrates necessary skills and knowledge to provide care for clients according to their needs.
• Demonstrates ability to handle emergency situations in a prompt, precise, and professional manner.
• Provides personal client care to promote comfort and well-being of the client acknowledging physiological and psychological needs.
• Promotes effective communication with all staff members and communicates pertinent information to the appropriate persons regarding the ongoing health status of each client in a timely manner.
• Ensures and demonstrates accurate and timely documentation.
• Accurately transcribes and/or follows physician orders according to policies and procedures.
• Performs other duties as may be assigned.

Values