The Registered Nurse is a member of the interdisciplinary team working in collaboration with the Physician. The Registered Nurse utilizes the nursing care process consistent with their license and/or certification including initiation of culturally competent continuum of care including inpatient, outpatient and community settings. The Registered Nurse is responsible to oversee any necessary coordination of the interdisciplinary plan of care and provides for its consistency with the medical treatment plan. The patient care process includes:
•Assessment - an orderly process consisting of the identification, gathering and organization of subjective and objective data pertaining to the patient/family/significant other, including physical, psychosocial, spiritual and cultural.
•Planning - an organized step in the process that consists of the identification of actual or potential problems and desired outcomes (goals) that result in a documented plan of care. The plan of care provides direction for the patient/family/significant other and interdisciplinary team.
•Intervention - the specific interventions or orders that are implemented consistent with the plan of care and medical treatment plan.
•Evaluation - a step in the process that involves determining the effectiveness of the interventions in achieving the plan of care and determining the conclusions concerning the achievement or lack of achievement of desired outcomes. The evaluation may initiate the need for reassessment and revisions to the problems, goals, plan of care, and interventions. This step provides for documentation of required actions. Based upon findings identified during assessment and reassessment:
•Patients have problems identified and prioritized relative to biophysical, psychological, environmental, self care, educational and social status.
•Goals are identified consistent with the problem to provide direction for patient care and health promotion.
•Education is consistent with the identified problem and associated goals and is seen as critical to creating an environment that promotes patient empowerment.
Licensed and registered care providers responsible for utilizing the care process relative to their scope of practice and knowledge base, may document the assessment, plan, intervention and evaluation. All patient care activities are administered according to standards, procedural guidelines and organizational policy.
The Registered Nurse actively supports performance improvement initiatives and provides leadership to other members of the patient care team. By participating in educational activities, the Registered Nurse assumes responsibility for continued professional and personal growth.
EDUCATION: Graduate of an accredited school of nursing; BSN preferred. Current licensure as a Registered Nurse in the State of New Jersey. BLSHCP required.
EXPERIENCE: Proficiency in Clinical Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.
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