Job Description Summary

Manages individualized, outcome oriented nursing care through the use of the nursing process. Provides care, treatment and services through the successful coordination and completion of a series of processes that include assessment, planning care, providing care, in accordance with departmental and hospital policies and procedures

Job Description

1. Medication Administration

a. Demonstrates knowledge of and follows SSH policies and procedures for administering, transcribing, and recording medications.

b. Completes medication reconciliation process following SSH policy and procedure.

c. 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.

a. Develop, evaluate and update individualized plan of care for patient and documents outcomes.

b. Initiating admission assessment within 8 hours of admissions, identifies and documents patient/family/significant other teaching needs upon admission and throughout hospitalization.

c. Continues assessment/reassessment and identifies care needs within established nursing practice.

d. 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)

e. 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.

f. Works on behalf of patient /family. Seeks help to represent patient/family when they are unable to represent themselves.

g. Raises ethical questions and concerns with clinical team. Seeks available resources to help formulate and understand ethical decisions.

h. Actively communicates plan of day via white board updating every shift.

i. 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.

a. Verifies patient identification with two identifiers prior to the start of any invasive procedure, including "time out