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This position provides nursing care under the direction and supervision of a registered nurse and/or licensed physician, and is accountable for the quality of nursing services delivered by self or others who are under his or her direction. This position observes, contributes to the plan of care, implements, reports and documents patient care in accordance with department policies, standard of care and state scope of practice. This position utilizes specialized knowledge, judgment, and nursing skills necessary to contribute to the assessment of data and to plan, provide and evaluate care appropriate to the physical and developmental age of assigned patients.
- Observes, compiles and reports the patient’s physical, psychological, social, spiritual, educational, developmental, cultural and discharge planning needs. Reviews available information obtained by health care team members.
- Contributes to plan of care under direction of registered nurse, including the discharge plan, utilizing assessment data and patient, family and health team input. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient in the plan of care. Plans care in collaboration with members of the multidisciplinary team. Reviews plan of care to reflect changing patient needs and provides input for updates as needed.
- Implements care based on delegated interventions identified in care plan and medical orders, within scope of practice. Provides care based on physician orders and the nursing plan of care, in compliance with policies and procedures, standards of care, and regulatory agency requirements. May delegate and provide supervision in the provision of care to non-licensed personnel, in accordance with state scope of practice. Promotes continuity of care by accurately and completely communicating to other caregivers the status of patients for whom care is provided.
- Reports condition of patient, including signs and symptoms which may be indicative of change in the patient’s condition to the registered nurse and/or physician. Observes and reports patient progress towards goals and expected outcomes in collaboration with other health care team members. Observes and reports patient’s response and the effectiveness of patient teaching.
- Documents observation, implementation and data in the patient record. Documentation reflects objective/subjective data, nursing interventions and patient’s response to treatment. Notes physician orders accurately and in a timely manner.
- May plan, organize, develop and coordinate the completion of documentation and the input of patient assessment data as required by federal regulation. Maintains, updates and revises required documentation according to patient changes in condition, as regulated by federal and/or state guidelines. Effectively communicates and coordinates with members of the interdisciplinary team regarding appropriate functional/care level and transition to another level. Performs audits related to the reimbursement documentation and the quality management process. Reviews audit results and presents summary information for management utilization and review.
- May coordinate the admission process including new resident evaluations. Provides verbal and written communication to residents, families and referrals sources regarding the process for admission to the center. Facilitates problem solving with residents, families, referral sources, insurance companies and clinical staff.
Must possess a current, valid LPN or LVN license in state of practice, temporary LPN or LVN license in state of practice, or compact LPN or LVN licensure for current state of practice. BLS certification is required. Additional certification or continuing education may be required based on area of practice. Completion of a state approved IV therapy program may be required in certain facilities and/or departments in accordance with state scope of practice, regulatory requirements or facility/ department policy. Banner Registry and Travel positions require a minimum of one year experience in an acute care hospital setting. Experience must include working in an acute care setting within the past 12 months as a LPN or LVN in the specialty area.
Experience in designated clinical area is preferred. Additional related education and/or experience preferred.