Staff Nurse-OPD Medical

Assessment and Diagnosis

Collects and analyzes assessment data to determine diagnosis/issues:

1. Assesses comprehensive data including but not limited to physical, psychosocial, emotional, cognitive, and spiritual needs and interprets assessment information to derive the diagnosis or issues as defined by the patient's condition.
2. Uses evidence-based assessment techniques and instruments in collecting data and validates the diagnosis or issue with the patient, family and healthcare team members as appropriate.
3. Prioritizes the data and information collected based on patient's immediate condition or anticipated needs and identifies potential risks or barriers to the patient's health or safety.
4. Documents the data and information collected in compliance with established guidelines and reflective of the needs of the patient.

Planning and Outcomes Identification

Identifies expected outcomes and develops a plan that addresses health promotion, health restoration and health maintenance to attain expected outcomes:

1. Involves patient, family and healthcare team members in formulating a culturally appropriate individualized plan of care.
2. Applies evidence-based nursing practices in developing the individualized plan of care to attain expected outcomes and continuity of care.
3. Modifies the individualized plan of care according to the ongoing assessment and reevaluation of the patient's response, status, and outcome indicators.
4. Documents the expected outcomes as measurable goals in a manner that uses standardized language or recognized terminology.

Implementation and Coordination of Care Delivery

Implements the plan of care in partnership with the patient, family and healthcare team members in a timely manner:

1. Utilizes evidence-based interventions and treatments specific to the needs of the patient.
2. Performs treatments and procedures according to established procedural guidelines and protocols.
3. Administers medications according to organization policies and procedures.
4. Ensures that all components of the individualized plan of care, including modifications, are documented in the patient’s health record.
5. Communicates relevant information across all levels of care and organizations.
6. Demonstrates a working knowledge of resource consumption and practices within a cost-effective framework.