You Will Be Responsible For:

·The RN is responsible for execution of the Nursing Process:   

· Assessment â“collects patient health data 

·Data collection involves the patient, family, and other health care providers as appropriate. 

·The priority of data collection activities is determined by the patientâ™s immediate condition or needs. 

·Pertinent data are collected using appropriate assessment techniques and instruments. 

·Relevant data are documented in a retrievable form. 

·The data collection process is systematic and ongoing. 

· Diagnosis â“analyzes the assessment data in determining diagnoses. 

·Diagnoses are derived from the assessment data. 

·Diagnoses are validated with the patient, family, and other health care providers, when possible and appropriate. 

·Diagnoses are documented in a manner that facilitates the determination of expected outcomes and plan of care. 

· Outcome Identification â“identifies expected outcomes individualized to the patient.

·Outcomes are derived from the diagnoses. 

·Outcomes are mutually formulated with the patient, family, and other health care providers, when possible and appropriate. 

·Outcomes are culturally appropriate and realistic in relation to the patientâ™s present and potential capabilities. 

·Outcomes are attainable in relation to resources available to the patient. 

·Outcomes include a time estimate for attainment, provide direction for continuity of care, and are documented as measurable goals. 

· Planning â“ works with the RN to develop a plan of care that prescribes interventions to attain expected outcomes. 

·The plan is individualized to the patient (e.g., age-appropriate, culturally sensitive) and the patientâ™s condition or needs. 

·The plan is developed with the patient, family, and other health care providers, as appropriate. 

·The plan reflects current nursing practice. 

·The plan provides for continuity of care. 

·Priorities for care are established. 

·The plan is documented. 

· Implementation â“implements the interventions identified in the plan of care. 

·Interventions are consistent with the established plan of care. 

·Interventions are implemented in a safe, timely, and appropriate manner. 

·Interventions are documented. 

· Evaluations â“evaluates the patientâ™s progress toward attainment of outcomes. 

·Evaluation is systematic, ongoing, and criterion-based. 

·The patient, family, and other health care providers are involved in the evaluation process, as appropriate. 

·Ongoing assessment data are used to revise diagnoses, outcomes, and the plan of care, as needed. 

·Revisions in diagnoses, outcomes, and the plan of care are documented. 

·The effectiveness of interventions is evaluated in relation to outcomes. 

·The patientâ™s responses to interventions are documented. 

·The RN practices in accordance to the established Georgia Nurse Practice Act and law.  

·The RN is responsible for maintaining general mandatories established by Gordon Hospital and any unit-specific mandatories, as deemed necessary for practice within that setting. 

·The RN is responsible for legal, ethical practice. The nurse serves as a patient advocate in accordance with the patient bill of rights. The nurse is responsible for compliance with regulatory standards pertinent to nursing practice.  

·The RN must remain flexible to changing systems, is expected to demonstrate quality and effectiveness in work habits and treats staff, physician, patients and families with consideration and respect.