Registered Nurse (RN) – Medical/Surgical Unit | Day Shift

1. Provides direct patient care utilizing the nursing process to assess, plan, implement, and evaluate care in accordance with the RN scope of practice, with the goal of achieving positive patient outcomes.

• Completes comprehensive admission assessments for assigned patients.
• Performs thorough nursing assessments efficiently and accurately.
• Conducts head-to-toe assessments and evaluates all body systems.
• Delivers nursing care appropriate to the assigned patient population, including Acute Care, Observation, Emergency, Skilled Nursing, and Outpatient services.
• Reviews provider orders, clarifies questions when necessary, and implements orders appropriately.
• Responds promptly to patient requests and call lights.
• Recognizes changes in patient condition, prioritizes care needs, and initiates appropriate interventions.
• Serves as an advocate for patients and their families.
• Completes purposeful rounding for assigned patients.
• Evaluates patient progress throughout hospitalization and prior to discharge.
• Demonstrates accountability by providing safe, professional, and compassionate nursing care.
• Initiates and manages intravenous therapies and related interventions.

2. Collaborates with physicians and the interdisciplinary healthcare team to coordinate and deliver quality patient care.

• Promotes effective teamwork through clear communication regarding patient status, care plans, and patient satisfaction.
• Partners with ancillary departments to ensure coordinated patient care.
• Provides appropriate direction and support to nursing assistants and other patient care team members.
• Demonstrates flexibility and initiative while meeting patient care needs.
• Communicates patient care concerns to the Lead Nurse or Nurse Manager in a timely manner.
• Assists with patient assignments, admissions, and daily staffing coordination as needed.
• Participates in interdisciplinary collaboration to support quality outcomes.
• Provides ongoing education to patients and families throughout hospitalization and during the discharge process.

3. Provides emergency nursing care within the RN scope of practice as patient situations require.

• Responds appropriately during emergency situations and assists with patient care based on the urgency of the situation.
• Prioritizes emergency care needs and utilizes additional resources when appropriate.
• Delivers emergency nursing care to patients across the lifespan, from newborn through geriatric populations, as applicable.
• Adheres to established emergency policies, procedures, and clinical protocols.

4. Maintains complete, accurate, and timely clinical documentation.

• Documents patient assessments, nursing interventions, patient responses, education provided, and discharge outcomes according to organizational standards.
• Completes all required end-of-shift documentation prior to leaving duty.

5. Demonstrates effective communication with patients, providers, and members of the healthcare team.

• Communicates patient status, care plans, and recommendations clearly with appropriate healthcare team members.
• Utilizes the approved handoff process during shift report to promote continuity of care.
• Identifies significant changes in patient condition, prioritizes interventions, and promptly notifies the appropriate provider.

6. Promotes a safe environment for patients, visitors, and staff.

• Administers medications, treatments, and procedures safely while following provider orders, nursing policies, patient identification standards, and required patient risk assessments.
• Uses appropriate body mechanics, lifting techniques, and transfer procedures to reduce the risk of injury to patients and staff.
• Follows infection prevention practices, including isolation precautions, hand hygiene, and appropriate use of personal protective equipment.
• Adheres to established procedures for narcotic wasting, sharps disposal, and hazardous waste management.

7. Functions in the Lead Nurse role when assigned by department leadership.

• Assists with oversight of daily patient care delivery, staffing, and unit assignments.
• Provides pharmacy coverage as assigned.
• Demonstrates knowledge of departmental equipment, treatments, policies, and procedures.
• Addresses patient and family concerns promptly and initiates appropriate interventions when possible.
• Adjusts to changing patient care needs while maintaining quality standards.
• Demonstrates initiative by completing responsibilities that support department operations, even when not specifically assigned.

8. Performs other duties and responsibilities as assigned.