Registered Nurse, Med/Surg

Job Code 523 CASS

REGIONAL MEDICAL CENTER

Job/Position Description Department Name:

Med/Surg Title:

Registered Nurse EEOC Classification:

Professional/Non-Exempt

PART ONE

Dimension and Description Primary Purpose :

To provide quality Patient care following the standards using the nursing process in order to maintain a safe environment to provide patient and family education and to provide proper documentation for billing.

Formal Policy-Setting Responsibilities:

Formally responsible for making recommendations regarding policies associated with the job's purpose and essential responsibilities.

Routine Decision Making :

Alterations in patient assessment; determines patient educational requirements; determines when to contact the physician.

Formal Supervisory Responsibility:

No formal supervisory responsibility.

Required Knowledge :

Nursing process; critical care; medications and treatments; growth and development; disease processes; interpretation of lab results.

Required Skills and Ability :

Good communication skills; assessment skills; time management skills; computer skills; clinic skills; problem solving skills; and knowledge of hospital policies and procedures.

Unusual Working Conditions :

Risk of blood, body fluid contamination. Risk for injury from aggressive, combative or disoriented patients. Education and Certification/ Registration Required for the

Position:

RN degree required, BSN preferred; current licensure in the state of Missouri; BLS required; NIH Stroke Certification required. PALS, ACLS, preferred.

Age Specific Competencies:

May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

PART TWO

Essential Responsibilities and Tasks A. Performs the assessment phase of the nursing process. (20% of time) 1. Assesses all assigned patients at start of shift. 2. Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four hours of arrival to the medical surgical unit. 3. Assesses data relative to age specific needs for every patient within four hours of patient's arrival to the unit or at start of shift. 4. Repeats assessment and documents on abnormal patient findings at least once and PRN during shift. 5. Assesses patient/family learning needs within four hours of arrival to the unit or at start of shift. 6. Completes appropriate pain assessment at start of shift and as needed. 7. Assesses the patient's and family's learning needs every shift. B. Performs the planning phase of the nursing process. (10% of time) 1. Completes an individualized care plan based on patient diagnosis and assessment with each admission. 2. Reviews and updates care plan each shift and PRN. 3. Collaborates with interdisciplinary team to facilitate the plan of care after the physician writes orders. 4. Interprets significance of abnormal patient findings after assessing patient on admission and as condition changes. 5. Updates white boards each shift, to include personalized patient goals and pain control. 6. Utilizing the "AIDET" model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals, and compliments at least one member of the patient care team each shift. C. Performs the implementation phase of the nursing process. (15% of time) 1. Implements patient care through team approach each shift. 2. Documents and reports significant abnormal patient findings to the charge nurse/physician immediately. 3. Is knowledgeable of location, care and operation of medical surgical equipment each shift. 4. Acts rapidly, effectively and manages self and others during emergency situations. 5. Administers IV's and medications as ordered within one hour of time scheduled according to the five rights on every patient. 6. Ensures all physician orders are correctly recorded on EMAR and in computer when acknowledging each order. 7. Accurately and correctly wastes used portions of controlled substances prior to the end of the shift. 8. Performs narcotic count according to hospital policy. 9. Attaches patients name band, fall risk, allergy band etc. immediately after patient's arrival and upon bands being removed. 10. Ensures fall protocol is followed on each patient. D. Performs the evaluation phase of the nursing process. (5% of time) 1. Evaluates each assigned patients response to care each shift and PRN. E. Provides patient and family education. (15% of time) 1. Provides patient and/or family's education based on assessments and re-assessments each shift. 2. Uses terminology appropriate to patient/family's knowledge base and age specific needs each shift. 3. Re-assesses patient and family's learning needs and abilities each shift. 4. Documents education provided including subject taught, method of teaching, who was taught, comprehension of information each shift. 5. Provides and documents patient and family follow-up instructions at discharge. F. Demonstrates accountability to the nursing process through documentation. (15% of time). 1. Documents assessments at least every shift and PRN. 2. Documents according to the plan of care at least once per shift. 3. Documents clearly the implementation of specific intervention, including details of methods used, with the time of implementation and evaluation of patient response. 4. Utilizes only approved abbreviations in patient documentation each shift. 5. Documentation follows hospital and departmental policies for frequency and content. G. Maintains a safe and comfortable unit. (10% of time) 1. Checks code blue carts each shift and upon using the cart ensuring it has an intact tag attached. 2. Ensures alarms on any assigned areas are audible to alert staff, each shift. 3. Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem. 4. Completes a requisition for repair and provides to purchaser's mailbox a copy before the end of shift. 5. Assigns/Completes, upon assignment, the job duty list for the unit each shift. 6. Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification. 7. Utilizes correct method of bar scanning patient identification bracelets for medication administration via EMAR 95% of the time. 8. Utilizes correct method of bar scanning patient medications for medication administration via EMAR 90% of the time. 9. Provides thorough handoff communication in report using Cass Regional report format on each patient. H. Develops and promotes hospital/ unit initiatives. (10% of time) 1. Plans, develops and evaluates self-objectives, annually. 2. Participates in planning ways to solve problems and make improvements in the medical surgical unit, quarterly, and as needed. 3. Participates in implementing planned changes and activities to improve the medical surgical unit quarterly, and as needed. 4. Evaluates planned changes and activities to improve the medical surgical unit, quarterly, and as needed. 5.

Participates on hospital/ unit teams:

3

• 2 or more teams, 2
• 1 team, 1
• no participation on teams.

6. Attends unit staff meetings 3 = greater than 6 meetings annually, 2 = 4 to 5 annually, 1 = less than 4 annually. 7. Bedside report to be performed each shift with the off going nurse. Report to include patient/family interaction. 8. Utilizing the "AIDET" model, conducts an appropriate introduction, discusses with patient ADL's and plan for the shift and compliments at least one member of the patient care team each shift. Purpose of AIDET directly relates to patient satisfaction scores and performance evaluation At Cass Regional Medical Center, we are keenly focused on helping each other thrive. With family as our core value, we believe support and encouragement make our bonds strong

• from how we treat each other, to how we treat our patients, to how we inspire a healthy community.

As one of the highest-ranking employees in Kansas City and a national leader for indeed work wellbeing, Cass Regional is a top choice for a healthcare career with purpose and satisfaction. We are proud of the recognition our employees give us in happiness, purpose, satisfaction and low stress environment. From our beautiful, modern and spacious campus to our patients who rave about our healthcare and our healthcare team

• we provide a career environment of wellbeing that 95% of our employees would recommend to their friends and family.

Registered Nurse, Med/Surg 3.8 3.8 out of 5 stars 2800 East Rock Haven Road, Harrisonville, MO 64701 PRN

CASS REGIONAL MEDICAL CENTER 28

reviews PRN Job Code 523 CASS

REGIONAL MEDICAL CENTER

Job/Position Description Department Name:

Med/Surg Title:

Registered Nurse EEOC Classification:

Professional/Non-Exempt

PART ONE

Dimension and Description Primary Purpose :

To provide quality Patient care following the standards using the nursing process in order to maintain a safe environment to provide patient and family education and to provide proper documentation for billing.

Formal Policy-Setting Responsibilities:

Formally responsible for making recommendations regarding policies associated with the job's purpose and essential responsibilities.

Routine Decision Making :

Alterations in patient assessment; determines patient educational requirements; determines when to contact the physician.

Formal Supervisory Responsibility:

No formal supervisory responsibility.

Required Knowledge :

Nursing process; critical care; medications and treatments; growth and development; disease processes; interpretation of lab results.

Required Skills and Ability :

Good communication skills; assessment skills; time management skills; computer skills; clinic skills; problem solving skills; and knowledge of hospital policies and procedures.

Unusual Working Conditions :

Risk of blood, body fluid contamination. Risk for injury from aggressive, combative or disoriented patients. Education and Certification/ Registration Required for the

Position:

RN degree required, BSN preferred; current licensure in the state of Missouri; BLS required; NIH Stroke Certification required. PALS, ACLS, preferred.

Age Specific Competencies:

May provide care for birth to pediatric (birth-2 yrs.), pediatric/child patients between (2 yrs-12 yrs); adolescent patients between 12 to 18 years of age; adult patients between 18 to 64 years; and geriatric patients 65 years and older.

PART TWO

Essential Responsibilities and Tasks A. Performs the assessment phase of the nursing process. (20% of time) 1. Assesses all assigned patients at start of shift. 2. Completes a patient admission assessment that includes a pertinent patient history, medication history, assessment of body systems and other screenings within four hours of arrival to the medical surgical unit. 3. Assesses data relative to age specific needs for every patient within four hours of patient's arrival to the unit or at start of shift. 4. Repeats assessment and documents on abnormal patient findings at least once and PRN during shift. 5. Assesses patient/family learning needs within four hours of arrival to the unit or at start of shift. 6. Completes appropriate pain assessment at start of shift and as needed. 7. Assesses the patient's and family's learning needs every shift. B. Performs the planning phase of the nursing process. (10% of time) 1. Completes an individualized care plan based on patient diagnosis and assessment with each admission. 2. Reviews and updates care plan each shift and PRN. 3. Collaborates with interdisciplinary team to facilitate the plan of care after the physician writes orders. 4. Interprets significance of abnormal patient findings after assessing patient on admission and as condition changes. 5. Updates white boards each shift, to include personalized patient goals and pain control. 6. Utilizing the "AIDET" model, conducts an appropriate introduction, reviews the plan of care, mutually sets attainable patient goals, and compliments at least one member of the patient care team each shift. C. Performs the implementation phase of the nursing process. (15% of time) 1. Implements patient care through team approach each shift. 2. Documents and reports significant abnormal patient findings to the charge nurse/physician immediately. 3. Is knowledgeable of location, care and operation of medical surgical equipment each shift. 4. Acts rapidly, effectively and manages self and others during emergency situations. 5. Administers IV's and medications as ordered within one hour of time scheduled according to the five rights on every patient. 6. Ensures all physician orders are correctly recorded on EMAR and in computer when acknowledging each order. 7. Accurately and correctly wastes used portions of controlled substances prior to the end of the shift. 8. Performs narcotic count according to hospital policy. 9. Attaches patients name band, fall risk, allergy band etc. immediately after patient's arrival and upon bands being removed. 10. Ensures fall protocol is followed on each patient. D. Performs the evaluation phase of the nursing process. (5% of time) 1. Evaluates each assigned patients response to care each shift and PRN. E. Provides patient and family education. (15% of time) 1. Provides patient and/or family's education based on assessments and re-assessments each shift. 2. Uses terminology appropriate to patient/family's knowledge base and age specific needs each shift. 3. Re-assesses patient and family's learning needs and abilities each shift. 4. Documents education provided including subject taught, method of teaching, who was taught, comprehension of information each shift. 5. Provides and documents patient and family follow-up instructions at discharge. F. Demonstrates accountability to the nursing process through documentation. (15% of time). 1. Documents assessments at least every shift and PRN. 2. Documents according to the plan of care at least once per shift. 3. Documents clearly the implementation of specific intervention, including details of methods used, with the time of implementation and evaluation of patient response. 4. Utilizes only approved abbreviations in patient documentation each shift. 5. Documentation follows hospital and departmental policies for frequency and content. G. Maintains a safe and comfortable unit. (10% of time) 1. Checks code blue carts each shift and upon using the cart ensuring it has an intact tag attached. 2. Ensures alarms on any assigned areas are audible to alert staff, each shift. 3. Removes malfunctioning equipment from the direct patient care area immediately upon discovering a problem. 4. Completes a requisition for repair and provides to purchaser's mailbox a copy before the end of shift. 5. Assigns/Completes, upon assignment, the job duty list for the unit each shift. 6. Utilizes correct patient identification by the hospital approved, two methods, for positive patient identification. 7. Utilizes correct method of bar scanning patient identification bracelets for medication administration via EMAR 95% of the time. 8. Utilizes correct method of bar scanning patient medications for medication administration via EMAR 90% of the time. 9. Provides thorough handoff communication in report using Cass Regional report format on each patient. H. Develops and promotes hospital/ unit initiatives. (10% of time) 1. Plans, develops and evaluates self-objectives, annually. 2. Participates in planning ways to solve problems and make improvements in the medical surgical unit, quarterly, and as needed. 3. Participates in implementing planned changes and activities to improve the medical surgical unit quarterly, and as needed. 4. Evaluates planned changes and activities to improve the medical surgical unit, quarterly, and as needed. 5.

Participates on hospital/ unit teams:

3

• 2 or more teams, 2
• 1 team, 1
• no participation on teams.

6. Attends unit staff meetings 3 = greater than 6 meetings annually, 2 = 4 to 5 annually, 1 = less than 4 annually. 7. Bedside report to be performed each shift with the off going nurse. Report to include patient/family interaction. 8. Utilizing the "AIDET" model, conducts an appropriate introduction, discusses with patient ADL's and plan for the shift and compliments at least one member of the patient care team each shift. Purpose of AIDET directly relates to patient satisfaction scores and performance evaluation At Cass Regional Medical Center, we are keenly focused on helping each other thrive. With family as our core value, we believe support and encouragement make our bonds strong

• from how we treat each other, to how we treat our patients, to how we inspire a healthy community.

As one of the highest-ranking employees in Kansas City and a national leader for indeed work wellbeing, Cass Regional is a top choice for a healthcare career with purpose and satisfaction. We are proud of the recognition our employees give us in happiness, purpose, satisfaction and low stress environment. From our beautiful, modern and spacious campus to our patients who rave about our healthcare and our healthcare team

• we provide a career environment of wellbeing that 95% of our employees would recommend to their friends and family.