VUMC Nursing : http://www.mc.vanderbilt.edu/root/vumc.php?site=vanderbilt-nursing

• Assessment of Health Status
• Performs and documents in the medical record a complete history and physical examination for acute and complex chronically ill patients.
• Orders and collects data using appropriate assessment techniques, relevant supporting diagnostic information and diagnostic procedures where indicated.
• The nurse practitioner may serve as the first responder for both nursing and house staff in the event of patient status changes, orders, and in situations requiring procedural and resuscitative interventions.
• Assesses for risks associated with the care of the acute and complex chronically ill patient including: medication side effects, immobility, impaired nutrition, fluid and electrolyte imbalance, immunocompetence, invasive interventions and diagnostic procedures.
• Coordinates daily rounds with the Attending physician teams, presents 24 hour patient report, collaborates in plan of care, and follows assigned patient population throughout the day.
• Diagnosis
• Collaborates with interdisciplinary health care team in making diagnoses of acute and complex chronic conditions.
• Manages diagnostic tests through ordering, interpretation, performance, and supervision.
• Formulates differential diagnoses by priority.
• Diagnoses complications and orders appropriate interventions
• Formulates Plan of Care
• Identifies expected outcomes from diagnosis, and formulates and documents a plan of care to address complex acute and chronic health care needs.
• Utilizes evidenced based practice guidelines or protocols in an individualized, dynamic plan of care that can be applied across the continuum.
• Implements and modifies plan of care
• Prescribes diagnostic strategies and therapeutic interventions both pharmacologic, non-pharmacologic and surgical, needed to achieve expected outcomes.
• Manages further diagnostic tests through ordering, interpretation, performance, and supervision.
• May perform advanced procedures consistent with privileges and competency validation including minor suturing, complex wound management, line and tube placements and removals.
• Communication and Collaboration
• Maintains ongoing communication and collaboration with interdisciplinary health care team .
• Facilitates and communicates with patient, family and staff to promote continuity of care across the inpatient and outpatient continuum of care.
• Documentation
• Documents/dictates key components of patient's progress via daily progress note, transfer, and discharge summary , and or clinic note where applicable. (h&p, daily progress notes, plan of care, problem lists, procedure notes, acute event note, discharge summaries, in medical record per specific patient unit or service, death summary)
• Documentation is timely, meets acute care compliance standards and captures patient acuity.
• Professional Practice
• Demonstrates Professional Practice behaviors including: preceptor/mentoring, education and instruction of students, nursing staff, nurses, graduate and novice nurse practitioners.
• Seeks opportunities for active engagement in research and the analysis of evidenced based practice.
• Actively participates in Grand Rounds, APN council meetings, faculty and unit meetings, M&M presentations.
• Maintains CEUs, and membership in a professional organization.