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    Registered Nurse - San Marcos, TX, United States - CHRISTUS Health

    CHRISTUS Health background
    Full time
    Description

    Summary:

    The competent Nurse, in the same or similar clinical setting, practices independently and demonstrates an awareness of all relevant aspects of a situation.

    Provides routine and complex care, with the ability to on long-range goals or plans. Continues to develop the ability to cope with and manage contingencies of clinical nursing. Makes appropriate assignments and delegates to other care providers as a means to help manage the clinical situation.


    Responsibilities:
    Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
    Consistent with the ANA Scope and Standards of Practice, provides nursing care utilizing the nursing process, including assessment, diagnosis, planning, intervention and evaluation for assigned patients
    Addresses increasingly complex psychological, emotional, cultural, and social needs of patient and families in accordance with their level of practice
    Using the appropriate protocol, administers medications and treatments; monitors for side-effects and effectiveness of the treatment prescribed
    Documents patient history, symptoms, medication, and care given
    Assess learning needs and provides education to patients, family members and/or care givers; identify issues and resources

    CORE COMPETENCIES

    Standard I:
    Utilizes the Nursing Process

    Uses critical thinking skills to assess the basic physical, psychosocial, social, cultural,
    Spiritual, and development needs of patient and families
    Communicates findings to appropriate healthcare team members

    Develops and uses a specific plan of care and modifies it to meet individual patient needs using evidence-based practice.

    Implements patient care and therapeutic procedures; monitors and documents progression of treatment and teaching goals
    Evaluates the care and treatment(s) provided to the patient and the patient response to the care and treatment(s).
    Performs timely reassessment and documentation
    Must be able to perform unit-specific competencies based on the specific patient care need for the designated unit's patient population
    Standard II. Patient Throughput & Patient Flow Process

    Anticipates and plans for admission/discharge/transfer needs to facilitate patient flow
    Utilizes appropriate systems of communication and tools to facilitate the discharge process
    Coaches on tools and techniques for checking, cross checking and validating orders to ensure accuracy.
    Standard III. Unit Operations

    Plans, directs, and evaluates the overall nursing care and functions in a particular nursing unit during an assigned shift
    Demonstrates good stewardship in proper use and maintenance of equipment and Supplies
    Assesses departmental staffing needs; actively participates in resourcing efforts.
    Educates and trains others on the operations, ethics, and regulations within the industry.
    Standard IV. Safe Practice/Quality Care/Regulations

    Incorporates patient safety practices/guidelines to promote a safe environment resulting in positive patient outcomes
    Demonstrates accountability for nursing research and quality improvement activities
    Provides evidence-based nursing care
    Communicates patient information effectively across the continuum of care
    Educates and trains others on the operations, ethics, and regulations within the industry.

    Knowledge of federal, state and local healthcare-related laws and regulations; ability to comply with these in healthcare practices and activities.


    TECHNICAL COMPETENCIES
    Clinical Policies and Standards

    Follows a specific set of standards and associated clinical procedures
    Analyzes policy and standards documentation and ensures organizational compliance
    Provides feedback for improvement of procedures
    Assists in the development and implementation of specific procedures
    Works with control and monitoring mechanisms, tools and techniques
    Health Information Documentation

    Shares experiences with maintaining paper and electronic patient documentation
    Walk through the steps and procedures for receiving, validating and updating patient records
    Describes the flow of information between various stations or units
    Discusses the functions, features and document flow of electronic documentation
    Transcribes verbal orders; explains techniques for ensuring their accuracy
    Explains health information documentation best practices and their rationale across health care practices.
    Medical Equipment

    Describes experience with basic medical equipment used in own unit or facility
    Uses standard diagnostic tools and techniques to resolves common equipment problems
    Educates patients about the appropriate use of home medical equipment
    Ensures that all equipment and related supplies are in proper working order prior to use to ensure patient safety
    Inspects, troubleshoots and evaluates incoming equipment
    Medical Order Processing

    Shares experiences with processing medical orders for one or more groups of patients or conditions
    Describes functions and features of the system used to enter, validate, update and forward medical orders
    Discusses common errors, their sources and procedures for correcting
    Explains considerations for entering and following standing orders
    Differentiates between standing orders and preprinted orders and considerations for each
    Patient Chart Reading and Interpretation

    Describes experiences in reading and interpreting patient charts for patients on unit and under own care
    Reviews patients' charts for completion and accuracy; identifies and alerts to mistakes or omissions
    Recognizes unexpected readings and alerts nursing or medical staff
    Relates examples of mis-readings or misinterpretations and lessons learned
    Reviews, discusses and validates own interpretation with others
    Patient Safety

    Shares experiences with ensuring safety for one or more patient groups or settings
    Explains key features of safety guidelines and procedures for those groups and settings
    Listens and responds to safety inquiries from patients and family members
    Recognizes and addresses physiological and psychological signs of problems
    Describes considerations for patients who can cause to harm to self, versus harm to others
    Utilizes appropriate systems to document misses and

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