- Provides direct and indirect nursing care in a professional manner based on the Physician Plan of Treatment and the nursing care plan:
- Conducts an individualized, accurate assessment of developmental, cognitive, cultural, psychosocial, spiritual, family influences and physical/medical needs.
- Demonstrates clinical competence in administering cares according physician orders, nursing care plan and policies.
- Performs and carries out cares and treatments according physician orders, company policies and procedures.
- Demonstrates knowledge of appropriate care for infant, toddler, preschool, school age and adolescent patients.
- Implements nursing actions in accordance with the plan of care and with respect for child/family individualized needs by incorporating child’s and/or caregivers preferences into care.
- Assesses patient/caregivers for understanding of treatment regime and ability to perform cares and provides ongoing education to patient and caregivers using an individualized approach in delivery style.
- Monitors and documents response to pain, cares, treatments and medications and evaluates outcomes of care provided, adjusting care process as indicated.
- Performs reassessments based on plan of treatment, company policy and changes in child’s condition and communicates changes to appropriate persons (Physician, Family, Team Leader, CNC) as indicated.
- Demonstrates age-specific competency in assessments of patient by the ability to obtain and interpret information in terms of patient needs, knowledge, growth and development, and understanding the range of treatment needed by the patient.
- Knows emergency preparedness plan and responds appropriately in crisis situations and/or life-threatening emergencies.
- Documentation reflects accurate assessment/evaluation, modification, and patient’s response to therapy, changes in conditions, and therapeutic interventions/procedures.
- Entries in medical record follow company policy such as correct date, time, use of appropriate, company approved abbreviations, etc.
- Documentation is completed within established timeframes including, but not limited to: Initial Assessment, Nursing Flow Sheet/Daily Charting, Progress Report Sheet, Sign-in Sheet, Teaching Log, Medication Record, Medication Profile, Developmental Assessment, Incident Report Forms, and Specialty Flow Sheets (Seizure, A&B, Cath/Stool, Height/Weight, Sprint, Dietary Log, etc)
- All charting is completed per policy to reflect accurate care for shift on proper forms, according to internal and external regulatory requirements and Physician orders.
- Completes and verifies accurate Physician orders entry into computerized orders and plan of treatment per policy
- Reviews and makes appropriate changes in the computerized nursing care plan and time schedule when patient’s condition/routine changes to accurately reflect plan of care
- Initiates new paperwork on clipboard, per policy to include but not limited to Nursing Flow Sheet, Current Orders/Daily Charting, Time Schedule, Medication Record, Progress Report Sheet, Sign-in Sheet, etc.