Job Description
Manages individualized, outcome-oriented nursing care through the use of the nursing process.
Provides care, treatment, and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, coordinating cross continuum care, and assessing outcomes of interventions in accordance with system, departmental, and ambulatory policies and procedures.
Essential Functions
1. Medication Administration
* Demonstrates knowledge of and follows SSH policies and procedures for administering and documenting medications.
* Completes medication reconciliation process following SSH policy and procedure.
* Demonstrates safe procedures for the safe administration of medication and vaccines.
2. Plan of Care/Documentation/Patient Family Centered Care/Patient Experience
* Develops, discusses, and communicates a prioritized problem and plan of care for each patient.
* Develops, evaluates, and updates individualized plan for patient and documents outcomes.
* Initiates patient outreach, identifies and documents patient/family/significant other needs and makes appropriate interventions, evaluating outcomes of interventions.
* Continues assessment/reassessment and identifies care needs within established nursing practice.
* Documents all patient care following the department of nursing policy, department-based standards, disease processes (CHF, PNA vaccines) and nurse-sensitive indicators (falls, safety risk, isolation, etc.).
* Assesses/reassesses and documents patient's response to each intervention both pharmacological and non-pharmacological per South Shore Health and ambulatory policies and procedures.
* Works on behalf of patient/family. Seeks help to represent patient/family when they are unable to represent themselves.
* Raises ethical questions and concerns with clinical team. Seeks available resources to help formulate and understand ethical decisions.
* Actively communicates and collaborates with health team members: primary care, specialty care, and ancillary providers and departments.
* Facilitates care across the continuum to ensure patient needs are met in the right setting and at the right time.
3. Safety/Quality
4. Fosters a