RN-OR
Company: SSM Health
Location: Saint Louis
Posted on: September 15, 2021
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Job Description:
The Registered Nurse is a professional practitioner who
assesses, manages, directs, and provides nursing care care
activities during the patient's hospital stay and coordinates
planning with other disciplines utilizing a patient/customer driven
approach. POSITION ACCOUNTABILITIES AND PERFORMANCE CRITERIA Essential Functions: The following are essential job
accountabilities and performance criteria: 1) Performs comprehensive nursing
assessment/reassessment. Criteria A) Performs age-appropriate admission
assessment or transfer assessment. Obtains input from
family/guardian when appropriate. B) Accurately and completely documents
findings. C) Performs assessment of
post-op/post-invasive procedure patients. D) Assesses and documents education and
discharge needs of patient and family on admission and
throughout hospitalization. E) Provides patient reassessment documenting
pertinent observations according to the patient plan
of care, changes in condition, status and/or diagnosis, response to
care, procedures, etc., and standards of
care. 2) Establishes, coordinates and evaluates a
plan of care based on analysis of assessment data,
patient diagnosis, lab data, tests, procedures, physician
orders, protocols and standards of care and other
information as relevant. Criteria A)Identifies short and long term goals based on patient
care needs. B)Formulates nursing interventions to achieve desired
patient outcome. C) Incorporates disease specific evidenced
based practice into nursing care plan and other
documentation 3)Provides and documents nursing interventions based on
assessed patient needs, plan of care, and changes in
patient status. Criteria A) Collaborates with appropriate health team
members for coordination of daily plan of care for
assigned patients. B) Provides, coordinates and communicates
patient care, including accurate Handoff Communication
Reports. C) Administers and documents medications
accurately according to policies and
procedures. D) Monitors, maintains and documents accurate
IV fluids and parenteral nutrition according to
policies and procedures. E) Completes referrals as indicated by
assessment data. F) Requests consultation for special needs,
equipment, or information for patient and/or
family. G) Provides patient/family education and
discharge planning per documentation guidelines and
protocol. H) Clarifies all physician orders as
warranted. I) Acknowledges and implements physician
orders in an accurate and timely manner as evidenced
by documentation in the medical record. J) Assists physician with
procedures/treatments as requested or delegates to Care
Partner as appropriate. K) Documents "Readback" for all
telephone/verbal
orders. L) Takes
telephone/verbal orders only in
emergency situations. M) Recognizes changes in patient's condition
and takes appropriate nursing actions. N) Involves the family/guardian when
providing care and in decision-making as
appropriate. O) Recognizes risks for patient and takes
appropriate action. P) Incorporates use of Infection Control
practices in daily care. 4) Documents and or communicates nursing care
and or changes in patient condition. Criteria A) Performs and documents ongoing evaluation
of effectiveness of care based on assessment data,
nursing interventions, patient response to medications,
treatments and procedures. B) Evaluates and documents effectiveness of
patient/family education. C) Evaluates plan of care and modifies as
indicated in "A" above. D) Recognizes significant changes in
patient's clinical parameters and reports immediately
to physician and others as indicated. E) Identifies problems, gathers pertinent
data, suggests solutions, communicates using
appropriate lines of authority, and works toward problem
resolution. F) Reports variation from care/treatment
following the occurrence reporting policy and
procedures. 5)Specialized Care: Provides specialized care to patients
at high risk for injury. Criteria A) Restraint Care 1. Initiates/evaluates alternatives to
restraint prior to application 2.Applies restraints consistent with the approved
procedure. 3. Monitors and assesses patient's response
throughout the restraint period at the appropriate
intervals. 4. Provides specified patient care
(toileting, skin care, hydration, feeding, etc.) on a
timely basis. 5. Provides consultation for peers to
determine alternatives to restraints and 1:1
observation. 6. Documents restraint use and associated
care thoroughly. B) Pain Management 1. Assess patient for presence of pain on
admission and during
assessments/reassessments. 2. Incorporates patient's cultural/spiritual
beliefs regarding pain into pain management
plan. 3. Implement pain management techniques.
Focus on prevention rather than treatment. 4. Include patient and/or family members in
developing a pain management plan. 5. Consider other methods of pain control when developing
plan of care: massage, repositioning, immobilization,
and music therapy. C) Abuse Assessment 1. Is aware of abuse recognition criteria and
incorporates it into assessments. 2. Reports signs of possible abuse/neglect to
the Administrative Director of Behavioral Health,
physician, Risk Management and Social Work. 3. Takes appropriate action to support
patient safety when signs of abuse are
noted. 6) Demonstrates accountability for own
professional practice. Criteria A) Adheres to all quality and performance standards,
policies, procedures, protocols when implementing
clinical and technical aspects of care. 1. Participates in learning experiences that
increases professional competence. B) Demonstrates appropriate technical and
cognitive skills for area of practice. C) Maintains currency in all hospital/unit
information, communication, policies and
procedures. 1. Attends staff meetings/reviews minutes
when absent 2. Participates in Committee(s), Shared
Governance, Work Team(s), in a leadership and or in
membership role 3. Reviews Hospital/Nursing
publications 4. Keeps up to date with policies and
procedures 5. Participates and or keeps up to date with
Shared Governance and Unit Based Practice Council
activities and information. Contributes to requests for
feedback. D) Demonstrates ability to change and adapt
to changing work demands 1. Responds positively to change 2. Provides assistance and support to peers,
co-workers and other team members 3.Adapts positively to changes in unplanned work load and
job demands 7) Ability to relate to coworkers in a
professional and appropriate manner. Criteria A) Orients and/or precepts new employees when
required. B) Participates in and maintains a
collaborative team approach toward work. C) Functions as a resource person to
co-workers, patients/families, medical staff and other
members of the health care team. D) Effectively assumes and delegates care and
other activities to the appropriate team
member. E) Redirects clinical staff when the medical
plan of care is altered. F) Communicates the plan of care to be
followed on each individual patient in a precise and
professional manner. G) Responsible for the supervision and
teaching of students/new staff nurses. 8) Safety/Infection Control: Performs job in
accordance with safety and infection control
policies. Criteria A) Practices standard precautions and
disposes of hazardous wastes per established
guidelines. B) Maintains a safe, clean, comfortable, and
therapeutic environment for
patients/families/employees in accordance to hospital
standards. 1. Maintains clutter free
environment. 2. Follows hand hygiene
procedures. 3. Utilizes Safe Patient Handling techniques
and equipment. 4. Keeps personal conversations/background
noise to a minimum. 5. Adheres to dress code. C) Reports risk management concerns using
eSRM. D) Assumes responsibility for completing all
annual mandatory requirements: 1. Maintains current license and
certifications 2. Maintain up to date BLS and HI 3. Annual TB Screening and Influenza
vaccination 4. Annual Ethics Training (Initial Ethics, if
new employee) 5. Annual Safety Training 6. Required Information Security
course 7. Required Abuse & Neglect course 8. Annual Blood Borne Pathogens training (if
required) 9. Coursework as assigned for .edu 10. Annual competency 11. Age/Population specific competency (if
applicable) 12. orientation competency (if new
hire) 13. Service Specific E) Reports variations from care/treatment following the
occurrence reporting policy and procedure. 9) Service: Provides service excellence to
the customers of Saint Louis University Hospital by
delivering timely, high quality care in a courteous and
respectful manner. Criteria A)Demonstrates care and courtesy 1. Provides prompt, respectful, courteous
service. 2. Meets physical, spiritual, psychological
and emotional needs of patients and
families. 3.Works with other members of the health care team to see
that call lights are answered promptly. 4. Apologizes for mix-up and
delay. B) Communicates effectively and maintains
confidentiality 1. Listens to staff/patient/family concerns
and addresses needs. 2. Explains procedures and all education in a
manner that staff/patient/family
understand. 3. Allows time for questions. C) Demonstrates competence and
collaboration 1. Provides accurate handoff
reports. 2. Provides quality care in accordance to
standards. 3. Shares knowledge with other departments to
facilitate work flow and continuity. D) Provides cost effect services 1. Uses resources wisely. 2. Recommends changes in practice that
increases efficiency and minimizes waste. E) Ensures that customer satisfaction is
maintained through the use of the "Principles and Commitments" of
the hospital AIDET and "One Mission, One Spirit". 10) Incorporates Performance Improvement and
Evidenced Based Practice into individual professional
practice. Criteria A) Assist in developing and implementing
nursing unit goals. B) Remains current with evidenced based
practice initiatives. C) Identifies opportunities for improvement,
participates in data collection when requested,
suggests solutions, communicates using appropriate lines of
authority and works toward problem
resolution. D) Participates in the performance/process
improvement process. 1. Assists in developing unit based
Performance Improvement and action plans. 2. Leads a performance improvement team when
requested 3. Contributes to data collection 4. Participates in evaluation of Performance
Improvement results. E) Participates in nursing research activities. F) Participates in Departmental and Hospital Performance
Improvement activities when warranted. G) Participates in occurrence reviews H) Contributes to the maintenance/improvement of all
nursing quality indicators. 11) Age Appropriate Care: Provides
age-appropriate care to: _____Adult
_____Geriatric Criteria A) Demonstrates knowledge and skills of
normal growth & development necessary to provide
services to the age of the patient served by the
department. B)Demonstrates ability to assess and interpret age
specific data to identify patient needs. C) Utilizes communication skills necessary to
interpret age specific responses to service and
interaction. D) Involves family or significant other in
decision making related to services provided. E)Demonstrates ability to provide service needed for the
age groups routinely served by the department
assigned. 12) Cost Effective Services Criteria A) Uses resources efficiently. B) Recommends change in practice that
increase efficiency and minimize waste. C) Documents chargeable supplies and
equipment used to provide care. D) Prioritizes responsibilities and completes
work on time. E) Utilizes non-clinical time in a
constructive manner, i.e. completing chart audits, .edu,
mandatory education requirements. DISCLAIMER: Performs other related duties as assigned or
requested. Job Specifications MINIMUM EDUCATION: RN licensure in the State of Missouri,
or new graduate of accredited school of nursing and must obtain
licensure within 90 days of graduation. WORKING CONDITIONS: May be exposed to the risk of blood
borne diseases. Exposure to unpleasant elements
(accidents, injuries, and illness). Subject to varying
and unpredictable situations. Handles emergency and
crisis situations. Subject to irregular hours. PHYSICAL REQUIREMENTS: Occasional prolonged
standing/walking. Occasionally lifts, positions,
pushes and/or transfers patients. Occasional reaching,
stooping, bending, kneeling, crouching.
Employee___________________________________________Date____________
Supervisor__________________________________________Date_____________ Department Director
__________________________________Date_____________
Administration________________________________________Date_____________ The above statements are intended to describe the general
nature and level of work being performed. They are not
to be construed, as an exhaustive list of all duties,
responsibilities, and skills required of personnel so
classified. An individual working in their job classification
must also perform specific tasks upon request by
supervisor personnel. Furthermore, the duties and
responsibilities for this job classification are subject to
change at the discretion of the medical
center. Practice Agreement For Nursing Staff Please read the below standards and
expectations. Standard (I understand that . . .) Our patients deserve care that sets the standard for
excellence and meets the needs of each and every patient
whose care is our primary purpose and mission.
(Quality) Expectations (So I will . . .) Achieve Excellence in Infection Control By: ?Achieve Excellence in Nursing Practice By: ?Own and Respect My Environment By: Standard (I understand that . . .) Treating my colleagues, our patients, visitors, and
business partners with respect and dignity is necessary to create
an environment where excellence in caring and nursing
practice can thrive. (People) Expectations (So I will . . .) Standard (I understand that . . ) ?Patients and their families are scared and
vulnerable. It is my responsibility to communicate through verbal
and non-vernal means that I am here to help.
(Service) Expectations (So I will . . .) ?The intent of this agreement is not to
provide a complete list of job responsibilities. Its intent rather
is to be a positive statement of concrete actions
which will ensure that nursing practice at Saint Louis
University Hospital sets the benchmark for excellence
in service, quality, and people. As a member of the nursing staff at Saint Louis University
Hospital, I understand that on behalf of my hospital,
our patients and my co-workers I will conduct myself according to
this agreement at all times. Staff Signature __________________________________________ Print
Name ___________________________________________ Date
_______________ Manager Signature _________________________________________
Print Name _________________________________________ Date
______________ 2/16/09
Keywords: SSM Health, St. Louis , RN-OR, Other , Saint Louis, Missouri
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