• Assesses patients on admission within specified time frames to include consideration of physical, psychosocial, cultural and spiritual needs
• Reassess each patients health needs whenever warranted b the patients condition and at least every shift utilizing the nursing processes after obtaining a systematic database
• Establishes a plan of care based on indefinite data from all appropriate sources
• Reviews and updates the plan of care for each assigned patient utilizing data obtained from reassessments.
• Administers oral, topical the parental medications utilizing the 7 rights
• Assesses and documents effectiveness/untoward effects of medications and treatments.
• Performs treatments and procedures with consideration of common nursing practice, hospital policy and procedure, sterile technique, standard precautions and patient privacy
• Documents response to are and addresses pain management, discharge planning needs, educations and progress towards goals.
• Documents in a legible and accurate manner to include date and time of entry, signature, and title.
• Educates patient/family based on his/her assessed needs and uses “Krames” where appropriate
• Interprets or analyzes diagnostic data and reports, and intervenes appropriately
• Promptly communicates change in patients’ clinical condition to physicians and other health care team members as appropriate.
• Uses SBAR communication for all handoffs
• Demonstrates consideration of patient rights including confidentiality, safety and patient participation in plan of care
• Evaluates and documents patient care provided and the effectiveness of patient teaching
• Participates in multidisciplinary care planning
• Demonstrates knowledge of application criteria for restrains and the ability to manage patients in restraints per policy
• Follows the National Patient Safety Goals
• Follows hospital policy on use of two patient identifiers
• Understands Disaster Plan and own role
• Understands how to activate the Rapid Response Team
• Completes orientation to Life Safety Standards - Code Blue, Code Pink (infant abduction, Haz Mat Spills, Code Red (Fire), Oxygen shut off valve.
• Follows hospital infection control policies.
• Demonstrates knowledge of blood transfusion policy and documentation
• Understand the Chain of Command and accesses it appropriately
• Washes hand before and after each patient contact
• Follows guidelines for Core Measures and vaccine control


ACLS Preferred
CA RN License
Recent MS Experience in acute care facility