Registered Nurse - Outpatient Pediatric Plastic Surgery

%  

of time

Essential Function (Yes/No)

Key Responsibilities

(To be completed by Supervisor)

30

Clinical Knowledge/Skills Management

Clinical Knowledge: Integrates evidence-based nursing theory and practical knowledge in patience care delivery. Maintains knowledge base consistence with new technology, procedures, and interventions specific to patient groups and their families. Assesses, plans, implements, and evaluates appropriate interventions for a patient’s current, changing or potential clinical status. 

Clinical Skill: Performs priority technical procedures (i.e. assist with tissue expansion, remove sutures, remove and apply dressing(s) as indicated) required by the area/department assignment and does so safely, legally, effectively, and efficiently. Utilizes computer technology for and maintains confidentiality of data collections, documentation, communication, and research. 

Clinical Organization: Utilizes the nursing process in providing care for a group of patients in accordance with all Department Policies and Procedures. Establishes and/or revises priorities for job/patient care activities based on acuity, resource availability, patient/family preference, and scheduled procedures. Seeks consultation, supervision, and/or assistance when unable to perform procedures effectively, safely, or independently.

30

Patient Care Management

Functions as patient advocate and facilitates patient/family participation in decisions regarding their care. Directs others in the delivery of patient care, as appropriate and holds staff accountable for completion of delegated tasks. Participates collaboratively as a team member to achieve desired patient outcomes. Initiates or maintains interventions to assure continuity of safe/effective care for patients: between units, between shifts, within hospitalization period, prior to admission and/or discharge, among contacts in the health care agencies. 

• Case Management: Contacts insurance carriers, home-health agencies, DME companies, caregivers, pharmacies, CCS, etc. to coordinate timely care. Facilitates communication between caregivers, providers and other necessary support services i.e. returning calls to pharmacies and caregivers to facilitate prescription orders and renewals. Assisting in creating/reorganizing teaching materials for patient education.  

• Medication Management: Works as part of a multidisciplinary team to obtain medication authorizations, coordinates medication ordering and assures safe medication administration. Assists with prescription refills. Documents and maintains a record of prescription refills, medication authorization and all patient interactions in the electronic health record.  

• Other Duties: Coordinates with operating room staff to assure that supplies, special equipment and medications are available for the patient. Maintains list of pending surgeries in the operating room of patients requiring implant, tissue expanders, and custom implants. Coordinates pre- and post-op photos as needed. Maintains and orders clinical supplies and forms for clinic. Responsible for ordering, stocking, data entry, and bookkeeping including purchase costs, sales income for injectables and skin care cosmetic products. Apprise residents of pre-op work-ups, patient transfers and changes in operating room schedules. Provide information to potential patients regarding procedures available at UCSF. 

20

Nursing Process/Documentation

Meets the Department of Nursing Documentation Standards by utilizing the nursing process as evidenced by documentation of the following:

• Assessment: Completes nursing history that includes patient and family medical history, psychosocial, cultural factors, nutritional and special needs of the patients’ physical status within department timeframes. Completes an ongoing pain assessment and management plan as needed. Assesses discharge and teaching needs at the time of admission and throughout each episode of care. 
• Planning: Uses the nursing assessment and other appropriate resources to formulate a multi-disciplinary care plan. Revises the multi-disciplinary care plan according to the current condition and change in needs of the patient. In response to data indicating potential or actual risk to individual’s health, initiates action to correct, reduce or prevent the risk. Provides and documents a rationale for actions or decisions based on scientific principles, standard of nursing practice, previous experience, and/or clinical judgment.
• Implementing: Prepares patients for and instructs them about specific diagnostic and therapeutic procedures and treatments. Performs patient care procedures required by scope of clinical assignment and in accordance with the Department and unit policy and procedures. Responds and participates in the management of emergency clinical issues. Administers medications and blood components safely. Performs waived laboratory testing according to departmental policy. 
• Evaluating: Documents patient outcomes and responses to nursing interventions. Utilizes theoretical knowledge and clinical skill to develop alternate nursing approaches to patient and family care. 
• Teaching: Identifies patient, family, and/or patient caregiver’s learning needs and potential barriers to learning. Identifies patient, family, and /or patient caregiver’s teaching interventions specific to patient’s diagnosis and ability to learn, collaborating with other disciplines as appropriate. Involves patient, family, and/or patient’s caregiver in teaching. Evaluates the patient, family, and/or patient caregiver’s response to teaching. Provides information to patients and families regarding pre-operative evaluations and post-operative expectations, wound care, drain care, and complications. Reinforces pre-operative teaching as indicated regarding blood donation, bowel preps, abstinence of tobacco, aspirin, and non-steriodal medication as indicated. Provides information on pre-operative tests (i.e. CT scans, MRIs) and scheduled rehab therapy (i.e. hand therapy, occupational therapy).

10

5

Professionalism

Professional Development:

Completes annual performance evaluation in accordance with departmental policies and unit practice. Identifies and meets own educational needs to enhance area of practice. 

Work Related Policies:  

Maintains current California RN license, CPR, and specialty certification and presents proof prior to expiration, per policy. Meets annual review requirements. Meets physical examination and PPD or chest exam requirements. Meets work schedule commitment. Follow departmental guidelines regarding attendance. Maintains flexibility in relation to patient assignment, shift assignment, and work assignment. Adheres to dress code, including appropriate identification. Complies with unit-related policies. Knowledgeable about and complies with all applicable infection control, health and safety policies and procedures as implemented by the Department and the Medical Center. 

Professional Responsibility:

Participates in Nursing QI and/or Performance Improvement activities. Complies with activities mandated by JCAHO/Title 22. Maintains knowledge of and adheres to established clinical and administrative policies and procedures. Ensures protection of patient rights and confidentiality in all interactions. Participates in patient care/ethics conferences as appropriate. Supports Medical Center cost containment efforts. Attends and participates in at least 50% of staff meetings. Reads meeting minutes and other department communications and integrates information into practice. Participates in research activities to enhance patient care as appropriate. 

5

Leadership

Uses an effective approach with patient and unit-related problems. Identifies actual and potential problems and participates in formulation/implementation of a plan for resolution of problems using appropriate resources. Reports unresolved patient and unit-related problems to appropriate individual(s) and/or department. Acts as a resource to other staff members in problem identification/resolution and current issues in own clinical area. Delegates duties and guides personnel in patient care delivery to ensure safe and individualized patient care. Fosters a collaborative approach to patient and staff related issues. Acts as a reliable and approachable role model/mentor for staff and students as a level appropriate to own stage of professional development. Recognizes and utilizes talents and strengths of staff members to improve care of patients. Delegates to and supervises LVNs, students, and other personnel as appropriate for their scope of practice. Participates in orientation of new and supplemental staff and in implementation of unit orientation program. Performs the role of charge nurse in accordance with Department and unit-based policy. 

100%

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