1. Medication Administration
- Demonstrates knowledge of and follows SSH policies and procedures for administering, transcribing, and recording medications.
- Completes medication reconciliation process following SSH policy and procedure.
- Demonstrates proper procedure for the documentation of narcotic withdrawal, administration, verifies count, wastes per policy and resolves narcotic discrepancy.
2. Plan of care/Documentation/Patient Family Centered Care/Patient Experience
Develops, discusses, and communicates a prioritized problem list/plan of care for each patient.
- Develop, evaluate and update individualized plan of care for patient and documents outcomes.
- Initiating admission assessment within 8 hours of admissions, identifies and documents patient/family/significant other teaching needs upon admission and throughout hospitalization.
- Continues assessment/reassessment and identifies care needs within established nursing practice.
- Documents all patient care following the department of nursing policy, unit based standards, disease processes (CHF, PNA vaccines) and nurse sensitive indicators (falls, skin, CAUTI)
- Assess/reassesses and documents patient’s level of comfort utilizing the appropriate pain scale and the patient’s response to each intervention both pharmacological and non-pharmacological per South Shore Hospital policy.
- Works on behalf of patient /family. Seeks help to represent patient/family when they are unable to represent themselves.
- Raises ethical questions and concerns with clinical team. Seeks available resources to help formulate and understand ethical decisions.
- Actively communicates plan of day via white board updating every shift.
- Facilitates discharge/transfer by goal of 12:00pm, communicates barriers utilizing chain of command.
3. Safety/Quality – Foster’s a “Culture of Safety” through personal ownership and commitment to a safe environment.
- Verifies patient identification with two identifiers prior to the start of any invasive procedure, including “time out”, administration of care, medications, labeled specimen’s an documents confirming the correct patient, procedure, site, equipment and consent.
- Complies with the current CDC hand hygiene guidelines through proper handwashing. Adheres to universal precautions, makes appropriate use of personal protective equipment at all times and appropriately disposes of hazardous materials. Maintains awareness of MSDS sheets and how to access.
- Ensures environment meets regulatory requirements at all times.
- Understands and is able to demonstrate individual roles and responsibilities in the event of hospital codes/emergency preparedness.
4. Professional Development: Assumes overall responsibility for own professional development by incorporating evidenced-based practice, research, and performance improvement initiatives as a part of ongoing nursing practice.
- Obtains at least 5 contact hours per year in area of practice.
- Practices within the legal boundaries of MA Nurse Practice Act. Directs other licenses and non-licensed personnel as assigned.
- Displays the ability to accept and respond appropriately to feedback and recommendations for change.
- Demonstrates professional working relationships with colleagues from all disciplines to promote a health work environment