Description

Job Summary



Responsible for the planning and delivery of care utilizing nursing processes: assessment, implementation, and evaluation. Oversees the plan of care, utilizes effective problem solving strategies, and applies evidence based practice. Supports and upholds quality standards of a Magnet designated hospital and Patient Bill of Rights. Practices under the supervision of the Nursing Manager/Director and has passion for learning, provides compassionate and family centered care for Same Day Surgery patients.



Job Specific Duties

• Supports the Service Recovery Program. Ensures that his/her behavior meets/exceeds acceptable Service Scores as measured by the Service Index. (SEI).
• Ensures completion of patient admission history. Prepares and accurately completes the discharge planning process accurately as per department and hospital policies and procedures.
• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
• Follows physician’s orders, administers, and reconstitutes medications when needed. Adheres to six rights of medication administration per medication administration policy.
• Ensures proper and safe sedation administration to patients and monitors recovery as per the Sedation Policy and Procedure.
• Performs reassessments as per policy and when there is a change in the plan of care or when an intervention is performed.
• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
• Collaborates with a multi-disciplinary team in daily care planning, as appropriate, and fosters a Family Centered Care Environment
• Communicates the patient’s progress including critical findings and changes in the patient’s condition with the physician. Performs and documents discharge planning per policy.
• Ensures all surgical procedure documentation is obtained, labs, consents, advance directives, custody documentation in a timely and accurate manner.
• Accesses Electronic Medical Record (EMR) and performs charge reconciliation according to hospital policy and completes accurate and timely documentation in the patient’s electronic health record.
• Communicates and documents critical lab results per hospital policy and procedures.
• Communicates with patients and families to review plan of care and solicits input and communicates any patient and family concerns to physician.
• Collaborates and rounds with a multi-disciplinary team in daily care planning rounds, as appropriate, and fosters a Family Centered Care Environment.
• Provides education and documents on patient/family teachings on health-related needs (i.e. disease, medications, treatments, pain, discharge, safety, nutrition, skin care, etc.).
• Promotes an “error free” working environment by consistently providing high-quality safe care as prompted (as per Universal Protocol Policy).
• Provides patient information and effectively completes the hand off process at shift change and patient reassignments. Utilizes Same Day Surgery checklist.
• Works to meet/exceed standards in achieving a 95% CEI by completing documents in a timely manner & being accountable to regulatory requirements of the DNV, CMS, DOH & other accrediting agencies.
• Accountable to optimize first case starts to prevent delay of patient care per departmental goal.
• Performs skin & structural assessment, takes measures to accommodate patient and ensures safe care, while ensuring no medication errors. Performs falls risk assessment & takes appropriate steps.
• Meets or exceeds unit standards in achieving a 95% CEI; completes documentation in a timely manner; accountable to regulatory and requirements of the DNV, CMS, DOH & other accrediting agencies.
• Assesses all body systems, ensure safe, effective, and efficient care delivery with emphasis on the absence of medication errors, avoidance of falls & reduction of pain post-op.

Qualifications

Minimum Job Requirements

• Registered Nurse RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) - maintain active and in good standing throughout employment
• American Heart Association BLS - must maintain active and in good standing throughout employment
• American Heart Association PALS - must maintain active and in good standing throughout employment within 2 years

Knowledge, Skills, and Abilities

• BSN degree preferred or currently enrolled in BSN program (requiring proof) within 6 months of hire.
• A minimum of 1year experience as an RN preferred.
• Nursing experience in a pediatric healthcare surgery setting preferred.
• Possesses proficiency in computers and Electronic Medical Record (EMR) and Cerner preferred.
• Career Development: National Certified Pediatric Nurse (CPN) and/or certification equivalent within 5 years of hire preferred.
• Possesses proficiency in computers and Electronic Medical Record (EMR) and Cerner preferred.
• Able to analyze and interpret data and utilize the information to make judgments regarding patient care.
• Effective verbal and written communication skills.
• Ability to positively influence, hold self, and others accountable
• Able to work effectively in collaborative environment.
• Ability to apply principles of evidence-based practice, analytical thinking, and service excellence in practice.
• Able to float within Surgical Services while maintaining the delivery of clinical excellence and high quality service.