Clinical Nurse - Med Surg

Under general supervision, following established policies, procedures, and professional guidelines, delivers nursing care to patients. Plans and implements nursing care; documents nursing assessments; identifies and reports situations requiring further intervention; formulates and communicates goal-directed plan of care; assures patient rights. Responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital and principles of quality improvement

Essential Functions

· Assesses and analyzes the health status of patients in assigned nursing unit in a comprehensive manner. Performs and/or assures completed assessments on all patients admitted within the designated time delineated in policy/unit standards.

· Performs on-going assessments and documents according to policy and procedure, reports significant findings of admission and on-going assessments to appropriate member of heath care team.

· Initiates discharge planning process with initial admission assessment.

· Plans patient care on assigned unit in collaboration with the patient, family, and health care team.

· Formulates individualized patient plan of care based on assessment data within the designated time delineated in policy/unit standards.

· Updates plan of care based on the patient assessment within appropriate time period.

· Directs, implements and coordinates patient care activities on assigned unit to ensure the delivery of quality care.

· Communicates the plan of care to other members of the healthcare team through daily worksheet conferences, verbally during the shift and shift report.

· Directs care team members in accordance with their scope of practice.

· Communicates and documents all patient care given including assessments, plan of care, interventions, patient response, and follow-up. Transcribes and directs the implementation of physician orders. Provides patient education based on assessed needs and evaluates understanding.

· Conducts ongoing evaluation of patient outcomes and documents effectiveness of planned and implemented interventions and strategies in relation to the plan of care within time frames per policy/unit standards. Includes patient and family in the evaluation process.

· Provides appropriate patient assessment and care specific to the needs of the patient populations served (e.g. age groups, patients of size; diagnosis-based).

· Demonstrates knowledge and awareness of the specific physical, psychosocial and developmental needs of patients as appropriate to the populations served.