General Summary

• Consistently expresses and demonstrates respect, compassion and courtesy for patients, family/visitors, and team members. Assists the clinical nurse in providing individualized patient care consistent with the mission and values of University of Maryland Rehabilitation & Orthopaedic Institute and in accordance within the scope of practice, professional, and regulatory standards. Assists the clinical nurse in providing care appropriate to the age, culture, ethnicity, spirituality, and individual diagnostic needs of the persons served. Accountable to the clinical nurse, patients and families for processes and outcomes during an episode of care. Serves as a fully engaged member of the interdisciplinary patient care services team. Participates in cost effective strategies that optimize patient outcomes.
• Must demonstrate the knowledge and skills necessary to provide care appropriate to the age, culture, ethnicity, and specific individual diagnostic needs of the patients served in his/her department. He/she must be able to assess and interpret data about the patient's status in order to identify each patient's specific needs and provide the care needed by the patient group (pediatric, adolescents and/or geriatric patient group, culture and diagnostic specific).
• Consistently expresses and demonstrates compassion and courtesy for patients. Extends courtesy and support to patient's families/visitors.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by the person assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Electronic/Paper documentation: Accurately and concisely records patient care along the continuum. Attends required training on electronic documentation. Demonstrates ability to document/enter data correctly in the medical record/EMR verified by chart review.
• Wound Care: Provides patient care to promote healing and maintain structural integrity of the skin under the direction of a Licensed Clinical Nurse. Performs skin care and hygiene for the patient requiring wound care as per the directions of the Licensed Clinical Nurse. Performs wound care dressing changes without medication as directed by the Licensed Clinical Nurse. Reports impaired skin integrity and/or wound impairment to the Licensed Clinical Nurse in a timely manner. Assists the Licensed Clinical Nurse with appropriate strategies and/or treatment measures to provide wound care.
• Pain Management: Promotes a level of comfort acceptable to the patient. Screens the patient for pain and reports abnormal findings to the Licensed Clinical Nurse. Completes annual competency for recognition of pain and pain scores.
• Performs patient intake screening: Obtains and documents vital signs, weight, height, and provides direct patient care which includes preparing patients for physical examination. Maintains efficient flow of patients. Identifies, records, and reports overt findings to the Licensed Clinical Nurse concerning the physical and mental condition of a patient.

May assist Licensed Clinical Nurses in assembling equipment and in performing various treatments and tests below:

• Gathers equipment required and initiates placement IV for the patient as directed by the Licensed Clinical Nurse. Performs venipuncture for drawing blood samples and established IV access.
• Performs urinary bladder catheterization for temporary or permanent placement and implements catheter care in stable patients as delegated by the Licensed Clinical Nurse.
• Cleans, sterilizes, and appropriately cares for equipment and instruments in accordance with operational procedure.

Communication/ Collaboration:

Works effectively with interdisciplinary team to provide patient care while using customer service skills and promote safety. Uses verbal, interpersonal, and teamwork skills to provide care along with other team members in a cohesive manner. Demonstrates a positive attitude in the work environment.

Collection of Specimens:

Accurately follows procedural guidelines and uses proper technique(s) to obtain bodily specimen collection for laboratory testing. Completes annual didactic and/or written testing with results kept on file. Incorporates proper techniques for patient identification, method for collection of appropriate specimens(s), and documentation.

Blood Glucose Monitoring (Accu-check):

• Able to accurately perform testing and manage the care of the patient based on results achieved and clinical findings. Attends annual training for review and receive updates on blood glucose testing and monitoring equipment. Demonstrates proper technique and skills needed for obtaining accurate blood glucose results and documenting findings.
• Completes annual didactic and/or written testing with results kept on file. Quality monitoring performance is assessed annually and/or as needed at intervals based on performance criteria.

Respect for individuals, Customer Service, Teamwork and Collaboration:

• Models' excellence in customer service behaviors. Identifies and acts on opportunities to respond to customer requirements. Takes action to prevent potential customer complaints.
• Initiates and reports service recovery steps taken in response to customer concerns.
• Demonstrates the ability to provide care appropriate to the age, culture, ethnicity, spirituality, and individual diagnostic needs of the persons served.
• Uses hands off communication to convey appropriate clinical/patient information
• Maintains confidentiality of patient information (HIPAA).
• Provides an inclusive environment for peers and team members.
• Provides performance feedback as requested within peer review systems.
• Voices difference in opinion professionally through appropriate channels.

Leadership, Clinical and/or Technical Skills:

• Demonstrates ability to complete delegated nursing tasks related to the patient population in the area of assignment.
• Contributes to the nursing process by collecting and reporting accurate data on the patient's health status.
• Collaborates with the interdisciplinary team to implement and evaluate the plan of care including the patient's response to treatment.
• Reports observed changes in patient's condition to appropriate clinician.
• Reports patient response to teaching provided by members of the interdisciplinary team.
• Demonstrates effective documentation of delegated nursing tasks according to standards of area assigned.
• Provides assistance to interdisciplinary team members as required to meet patient care requirements.
• Supports unit/organizational goals and problem solving initiatives as a fully engaged member of the team.
• Other duties, as assigned.

Quality and Patient Safety:

• Ensures the safety of the clinical environment for patients, visitors, and other staff members.
• Demonstrates knowledge, practice, and accountability for compliance with the TJC National Patient Safety Goals within scope of practice.
• Detects, reports, and takes action to avoid or correct safety risks.
• Reports adverse events and near misses to appropriate management authority.
• Assists in implementation of fall prevention strategies.
• Incorporates safe lifting techniques and body mechanics in daily practice.

Cost Effectiveness:

• Acts on opportunities to improve patient flow and prevent care delays.
• Employs practices that improve efficiency, reduce costs, and maximize charge capture when delivering patient care.
• Demonstrates effective priority-setting and time management skills.
• Inputs efficient and balanced self-scheduling data in compliance with staffing targets and guidelines
• Demonstrates awareness of cost implications of practice patterns and identifies methods to improve.

Education and Research:

• Assumes responsibility for maintaining competency and clinical knowledge base related to role.
• Identifies and addresses learning needs of self.
• Attends required in-services. Completes written and/or computerized training.
• Participates in data collection for approved research projects as assigned.