Clinical Nurse

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.