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 Minor Procedure Suite 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.
  
• Completes all nursing multi-system assessments that include head to toe, vitals, pain management, falls risk assessment, post anesthetic scores, and airway management.
  
• Ensures completion of patient pre-admission/admission history and prepares and accurately completes the discharge planning process accurately as per department and hospital policies and procedures.
  
• Communicates and documents the patient’s progress including critical findings, changes in patient’s condition with the physician or disciplines involved in the care of the patient.
  
• Implements and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
  
• Provides nursing care that includes IV site monitoring, specimen collection, and assists surgical team with specific procedures.
  
• 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 PACU Policy and Procedure.
  
• Cross trained to provide safe patient care in Pre-Op, Intra-Op, PACU 1, and PACU 2.
  
• Leads turnover between cases with Care Assistants to provide safe and clean environment of care.
  
• Ensures advanced directives, secures blood consents, documents time-out procedures, and ensures the correct site/side is marked (when applicable per Universal Protocol Policy).
  
• Greets family and patient, transports patient into OR. Acts as liaison to update family with procedure progress to ensure top tier patient and family satisfaction (SEI index).
  
• Collaborates with a multi-disciplinary team in daily care planning, as appropriate, and fosters a Family Centered Care Environment.
  
• Remains with the patient during emergence and intubation and assists Anesthesia team as needed.
  
• Transports the patient to recovery room and completes the SOAR checklist for the procedure with transition of care performed with a hand-off to the PACU RN.
  
• Plans, implements, and documents the plan of care in collaboration with the other disciplines and services to assure safe and efficient care.
  
• Performs reassessments as per policy and when there is a change in the plan of care or when an intervention is performed.
  
• Accesses electronic health record independently 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.
  
• Ensures all surgical procedure documentation is obtained (i.e.; labs, consents, advance directives, custody documentation) in a timely and accurate manner.
  
• Educates patients and families about the medical procedure, diagnosis, and discharge instructions.
  
• Communicates with patients and families to review plan of care and solicits input. Communicate 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.).
  
• Communicates and documents critical lab results per hospital policy and procedures.
  
• Promotes an “error free” working environment by consistently providing high-quality safe care as prompted (as per Universal Protocol Policy).
  
• Assesses all body systems, ensures safe effective, and efficient care delivery with emphasis on the absence of medication errors, avoidance of falls & reduction of pain post-op.
  
• Provides patient information and effectively completes the hand off process during patient reassignments as per SOAR document.
  
• Responsible for proper PPE indication and use.
  
• Accountable to optimize first case starts to prevent delay of patient care per departmental goals.
  
• Actively participates in hospital-wide committees and unit based committees on turnover or first case starts and utilizes lean processes.
  
• Performs skin & structural assessment, takes measures to accommodate patient & ensures safe care while ensuring no medication errors. Performs falls risk assessment & takes appropriate steps.
  
• Accountable to ensure the proper steps are followed in the processing of Gastro Intestinal scopes per departmental policy/protocol which meets infection control standards.
  
• Meets or exceeds unit standards in achieving CEI standards; completes documentation in a timely manner & accountable to regulatory requirements of the DNV, CMS, DOH & other agencies.
  
• Promotes safety by actively practicing time-out. Documenting all implants and blood transfusion products per the Surgical Services Policy on blood transfusions, implants, and time-out procedures.