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.