The Registered Nurse (RN) is the patient and patient’s family advocate. The RN consistently applies and utilizes the nursing process, critical thinking skills, scientific judgment, technical skills, and leadership to independently deliver safe nursing care to patients. The RN collaborates with the patient care team to achieve quality patient outcomes. Communicates and utilizes interpersonal skills effectively and role models confidence and professionalism within nursing by active engagement in unit and organizational activities. Demonstrates team work, adaptability, and is a resource person to the patient care team. The RN is accountable for the quality of nursing care services delivered by self or others under their direction in accordance with the Texas Nurse Practice Act, hospital policies, and the Texas Board of Nursing rules for delegated nursing tasks (Chapter 224). Essential Job Functions: Applies nursing judgment through a thorough, systematic approach of applying the nursing process, to include: Assessment: Conducts ongoing focused physical, psychosocial, and pain assessments; includes assessment of patient education needs. Planning: Utilizes the assessment, identifies problems, makes nursing diagnoses, formulates goals, teaching plans and outcomes to create an individualized plan of care. Identifies individual patient goals, readiness to learn, and incorporates family into the plan of care. Implementation: Prioritizes and implements an efficient nursing plan of care. Evaluation/Reassessment: Consistently conducts timely evaluations, recognizes changes in patient conditions, determines when reassessments are needed, and adjusts the plan of care as necessary. Compares expected and achieved outcomes of nursing care utilizing the plan of care. Collaborates with patient care team members on patient care plan, incorporating consistent use of hand-off communication and SBAR communication methods. Prioritizes tasks and adjusts priorities when necessary. Maintains an orderly, efficient, and timely flow of patients. Recognizes and reports errors or unusual occurrences, and initiates corrective action when appropriate. Makes accurate, complete, and timely entries into the patient medical record addressing all steps of the nursing process. Actively communicates with members of the healthcare team, patient, and patient family. Maintains current nursing knowledge to assure a safe working environment.
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