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.