Under general supervision and in collaboration with other members of the health care team, uses clinical judgment skills to diagnose and treat human responses to actual or potential health problems. The RN is responsible for assessing, planning, directing, providing and evaluation nursing care for patients and coordinating nurses care activities with other health care disciplines.

• Assessment:
  
  
  
  • Performs accurate multi-system assessments, including biophysical, psychosocial, environmental, self-care, education needs and discharge planning needs.
  
  
  • Identifies deviations from normal on routine lab diagnostic tests. 
  
  
  • Reassesses patient throughout hospitalization. 
  
  
  • Performs complete discharge assessment.
  
  
  
  


• Planning:
  
  
  
  • Develops an individual nursing plan of care.
  
  
  • Nursing plan of care is sensitive to the developmental needs of the patient. 
  
  
  • Coordinates patient care activities and discharge planning with other hospital and clinic departments and community agencies.
  
  
  • Develops patient teaching plan and documents on care plan or teaching plan. 
  
  
  • Appropriately delegates patient care activities based on patients' condition and scope of practice of other health care providers. 
  
  
  • Established priories for patient care.
  
  
  • Classifies acuity level of assigned patients.
  
  
  
  


• Implementation:
  
  
  
  • Initiates appropriate measures based on protocol for the management of the medical and/or surgical patient.
  
  
  • Bases nursing care on protocol in place for management of each patient. 
  
  
  • Correctly carries out the physician's plan of care.
  
  
  • Accurately documents in the emr. 
  
  
  • Documents care according to policy and procedure.
  
  
  • Utilizes a multidisciplinary approach when appropriate. 
  
  
  • Performs all necessary procedures correctly. 
  
  
  • Utilizes available teaching plans in addressing patient teaching needs.
  
  
  • Accurately calculates and administers medications.
  
  
  • Initiates appropriate measures in emergency situations.
  
  
  
  


• Evaluation:
  
  
  
  • Evaluates assessment methods, plan of care, and patients' response to treatment.
  
  
  • Participates in unit quality assurance activities.