Assessment Collects comprehensive data pertinent to the patients health or the situation. Completes initial assessment within 24 hours of admission or established policy time frame if sooner. Completes physiological, psychological, spiritual, and educational assessment of the patient/family within established policy time frame. Maintains ongoing assessment following established practice guidelines that accurately reflects patient status. Documents nursing assessment clearly and concisely. Notifies physician of pertinent changes in patient status.
Diagnosis Analyzes the assessment data to determine the diagnoses or issues. Identifies issues/ problems in Care Graph within established patient population time frames. Updates, adds or deletes issues/problems as patient condition changes.
Outcomes Identification Identifies expected outcomes for a plan individualized to the patient or the situation. Identifies realistic and measurable outcomes which are complimentary to medical plan of care and centered on the patients and family's/significant other's needs and appropriate practice guidelines.
Planning Develops a plan that prescribes strategies and alternatives to attain expected outcomes. Collaborates with co-workers, physician, other disciplines, patient, and family to develop individualized plan of care to address patient diagnoses or issues that attains patient outcomes. Revises plan of care based on evaluation of patients response. Includes discharge planning needs in plan of care. Implements the identified plan.
Coordinates care delivery - Assumes responsibility for assigning and coordinating patient care with ancillary personnel consistent with patient needs, staff competencies and licensure. Employs strategies to promote health and a safe environment . Demonstrates competence in the administration of age appropriate patient care and implementation of physician orders. Implements age appropriate patient care in accordance with established practice guidelines, policies, procedures, state and federal law. Facilitates a healing environment for patients through an evaluation of current hospital practice as it relates to the individual patient's welfare, i.e. patient needs for rest, nourishment, exercise, emotional, and spiritual support. Serves as a patient advocate. Communicates response to care, i.e. documentation and verbal report. Responsible for providing education for patients and their families regarding the patient's illness, treatment, medications, and discharge planning needs.
Evaluation Evaluates progress towards attainment of outcomes. Regularly evaluates the effectiveness of the coordinated medical and patient-centered plan of care and implements changes as necessary. Encourages feedback from the patient, families/significant others, peers, and other disciplines regarding perception of care provided to patients and utilizes feedback to improve patient care practices. Consistently conforms to high standards of professional performance.
Quality of Practice - Systematically evaluates the quality and effectiveness of nursing practice.
Education Attains knowledge and competency that reflects current nursing practice, including progression towards goals from previous evaluation/orientation completion. Professional Practice
Evaluation Evaluates own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rules, and regulations.
Collegiality Interacts with and contributes to the professional development of peers and colleagues.
Collaboration Collaborates with patient, family and others in the conduct of nursing practice. Seeks supervision, consultation, or assistance when unable to perform effectively or safely.
Ethics Integrates ethical provisions in all areas of practice. Provides care consistent with the Code of Ethics for Nurses. Practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. Primary commitment is to the patient, whether an individual, family, group, or community. Promotes, advocates for, and strives to protect the health, safety and rights of the patient. Responsible and accountable for individual nursing practice and determines appropriate delegation of tasks.
Resource Utilization Considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of nursing services.