- Observes the health status of patients and communicates this information to the RN. Completes those portions of the patient assessment as directed by the RN and as ordered in the physician plan of care: Skin condition, color, temperature Vital signs including pulse location, strength, and regularity Level of consciousness Edema including location and character Color, amount, and character of urine Color, quantity, and character of stools Presence or absence of bowel and breath sounds
- Collects data from the patient, family, significant others, health care providers, individuals and/or agencies in the community to include but not limited to: Chief complaint History of present illness Allergies Medications taken Past medical history Activities of daily living Perception of illness Personal hygiene Mental status Physical status
- Implements the patient care plan by providing direct care for those patients assigned and/or in immediate need of care.
- Documents patient care interventions and outcomes and communicates them to team members for follow through.
- Documents accurately in the patient record all activities. Completes documentation using real time charting updates patient care plans
- Communicates assessment data in an orderly fashion by recording, updating, and communicating among the nursing team; revises information according to patient changes.
- Collaborates with patients, famillies, health care team members and outside doctors' offices to establish of patient care.
- Collaborates with members of the healthcare team to facilitate coordinated delivery of care across the continuum.
- Participates in Interdisciplinary Team meetings and patient care conference.
- Utilizes resources in an economical manner
- Participates in professional development activities
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