Practices vocational nursing skills under the direction of an RN and seeks assistance from the RN as appropriate.
Appropriately assesses and documents the patient’s initial condition and assesses and documents ongoing changes. Participates in patient interventions, plans for care, and evaluation of care under direction of an RN.?Demonstrates ability to thoroughly assess patient’s condition and document using focus charting.
?Documents patient problems, interventions, and outcomes using focus charting.
?Assesses and documents patient’s on-going condition and any change in condition.
?Demonstrates knowledge of the Nursing Process by correctly utilizing focus charting.
- Plans and initiates patient teaching as related to the patient’s illness. Includes teaching and psychosocial interventions with both patients and family.?On admission, assesses patient’s learning needs and documents those need in the nursing record.
?Documents the plan of teaching, interventions taken, and their outcomes.
?Documents patient’s response to their illness, including psychosocial interventions with both patients and family and their outcome.
- Participates and documents discharge planning for the patient on initial admission and throughout the hospital stay.?Initiates and documents need for Discharge Planning on admission assessment
?Documents discharge planning, equipment needs, or home health needs throughout the length of the hospital stay.
- Participates in unit-based quality assurance activities.?Participates, as directed by RN, in ongoing unit-based monitors.
?Participates in problem solving based on findings of unit-based monitors.
- Administers and monitors the effects of medications as prescribed by a physician and in accordance with practice at Seton Medical Center.?Consistently charts sites of injections.
?Consistently charts effects of pain medications on record.
?Consistently monitors the effects of all medication, documents and informs the registered nurse of any untoward effect.
- Performs venipuncture following the standard of practice at Seton Medical Center.?Consistently follows IV policy as written at Seton Medical Center
?Charts and documents appropriately in the Medical Record when administering IV fluids and blood products (as per transfusion policy)
?Changes IV sites and documents such according to Seton Medical Center
- Demonstrates ability to document information in the patient record in a timely, concise manner.?Charting is legible and concise at all times.
Charting accurately reflects the patient’s clinical status.
- Demonstrates participation in professional self-development?Shows initiative in attending inservices and workshops appropriate to professional
?Document evidence of continuing education courses as required for licensure.
- Use effective oral and written skills to communicate with the members of the health care team, as well as patients and their families.?Demonstrates courteous and therapeutic communication with patients and family.
- Displays courteous and professional behavior while interacting with members of the health care team.
- Shows appropriate leadership skills while directing other members of the health care team.?Participates in orientation of new employees and registry personnel.
?Directs courteous and professional behavior while interacting with members of the health team.
- Performs appropriate duties as assigned by a Registered Nurse.?Willingly performs tasks for other members of the health care team when needed.
?Show initiative in performing duties outside of assignment.
?Uses oral and written skills in effectively communicating to other health team members, patients, and families.