JD-PE-Lic Clin Pos - UCLA Health
| |Job Description |
| |Performance Evaluation |
| |Period Covered by this Performance Evaluation: _____________ TO _______________ |
RN- UCLA Westwood Medical Center
|Employee Name: |Department/Unit: |Current Title: |Current Title Code: |
| | |CN I, II, III | |
|Supervisor Name: |Supervisor Title: |Approved Title (for reclassifications only): |Approved Title Code (for reclassifications only): |
| | | | |
|Methods of Measurement Include the Following: |AGES SERVED |
| Direct Observation | Documentation | Neonates (< 30 days) | Adults (> = 18 years to < 65 years) |
| Feedback from staff or patients | PI Reports | Infants (> 30 days and < 1 year) | Geriatric (> = 65 years) |
| | Pediatrics (> = 1 year & < 13 years) | Not Applicable |
| | Adolescents (> = 13 years & 18 years) | |
|Place an “X” if over 20% of work is exposed to one or more of the following conditions: |
| Confined area | Noise Exposure | Extreme temperatures | Potential allergenic/irritant conditions |
| Exposed to weather | Vibrations | Atmospheric conditions | Other (specify) |
|Please check all that apply (Competencies must be up-to-date at time of Performance Evaluation) |
|COMPETENCIES: |
|INITIAL: UCLA Healthcare Dept. Specific Orientation Department of Nursing and Service Unit (Float excluded) |
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|ANNUAL: Department of Nursing Unit (Float excluded) |
|SUMMARY STATEMENT: |
|The staff RN is a professional caregiver who assumes responsibility and accountability for a group of patients for a designated time frame and provides care to these patients via the nursing process and other input |
|from healthcare team members. |
|TYPE OF SUPERVISION RECEIVED: |
|Under direct supervision of the Unit Director and Clinical Nurse Specialist-Supervisor, the primary responsibilities of the clinical nurse include the direct nursing care of patients utilizing the nursing process; |
|development and application of leadership, management, and communication concepts; teaching of patients and staff; maintenance of professional standards. |
|Duties and Tasks |Rating |
| |D |M |N/A |
|PATIENT CARE | | | |
|Assessment/Reassessment | | | |
|Completes and documents an age appropriate admission assessment within 24 hours of admission | | | |
|Collects patient data by interview, review of current/prior medical records, diagnostic test results and collaboration with the healthcare team | | | |
| Assesses and documents patient’s cultural, psychosocial, psychological, and physiological status | | | |
| Assesses and documents patient’s need for dietary, functional, social work, discharge planning, and / or other healthcare provider referrals on admission. Initiates required referrals | | | |
|through appropriate channels and documents referrals made | | | |
| | | | |
| Analyzes assessment data and identifies actual and potential patient problems to be addressed during this hospitalization | | | |
|Recognizes and documents abnormal assessment findings or significant changes in patient’s condition | | | |
|Reassesses assigned patients at the beginning of the shift and at specified intervals throughout the shift and when the patient condition warrants reassessment and documents findings | | | |
|*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently focus on the most significant patient problems | | | |
|*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to identify and document subtle changes in the patient’s condition | | | |
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|Plan of Care | | | |
| | | | |
|On admission: | | | |
|Involves the patient/family/significant other in the development and documentation of relevant, measurable patient goals from the patient problems identified during the admission | | | |
|assessment | | | |
|Incorporates and documents the patient's advance directive in the plan of care | | | |
|Recognizes, incorporates and documents patient individuality, culture, ethnicity, spiritual beliefs, gender, race, age, disability, lifestyle and values into the plan of care | | | |
|Selects and documents appropriate standards/guidelines in the plan of care to meet patient goals | | | |
|Incorporates the treatment goals of the healthcare team into the patient’s plan of care | | | |
|Communicates patient’s goals/care plan during inter-shift report | | | |
|*Develops and documents plan of care for complex patient care problems involving multiple resources | | | |
|*Utilizes experience and in-depth knowledge to effectively modify and document changes in nursing care and/or the plan of care to address complex patient care problems | | | |
|*Mentors CN I, CN II in developing and documenting patient goals/care plan | | | |
|Interventions | | | |
| Utilizes communication strategies and behaviors that convey compassion and caring | | | |
| | | | |
| Utilizes communication points identified by the organization to send a consistent | | | |
|message to improve the patient and family experience | | | |
| Establishes priorities according to patient care needs and unit resources | | | |
| Provides, directs and documents age appropriate care to patients based on: | | | |
|the plan of care and medical orders | | | |
|patient preferences and | | | |
|consideration of cultural, psychosocial, psychological and physiological factors | | | |
|Demonstrates critical thinking, a global grasp of the patient’s condition, and an | | | |
|integration of formal and experiential knowledge in clinical decision making | | | |
|Ensures basic patient hygiene needs are met and documented | | | |
|Ensures patient safety by following hospital policies with focus on: | | | |
|Accurate patient identification | | | |
|Administration and documentation of medications | | | |
|Administration and documentation of blood products | | | |
|Prevention and documentation of patient injury and falls, and | | | |
|Use and documentation of restraints | | | |
|As a patient advocate: | | | |
|Assists patients and families in coping with difficulties associated with their illness and hospitalization | | | |
|Acts with a sense of urgency to meet patient care needs | | | |
|Identifies and corrects unsafe patient care practices and notifies risk management | | | |
|Identifies ethical issues and participates in their resolution | | | |
|Ensures that effective pain management interventions are implemented and documented to obtain adequate relief for patients’ pain | | | |
|Collaborates with the healthcare team throughout the patient’s hospitalization to address patient’s spiritual, cultural, psychological, psychosocial, physical and emotional needs and | | | |
|documents interventions | | | |
|Utilizes the appropriate chain of command to address abnormal and significant changes in the patient’s condition or an unmet patient / family concern/need and documents actions taken to | | | |
|advocate for the patient | | | |
|Initiates and documents appropriate interventions in predictable, unpredictable, pre-emergent and emergent patient care situations | | | |
|*Collaborates with medical staff in managing pre-emergent and emergent patient care situations | | | |
|*Collaborates and coordinates with healthcare providers in managing complex patient problems | | | |
|*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently implement and document nursing care interventions that address complex patient | | | |
|care problems | | | |
|Evaluation | | | |
|Evaluates and documents patient's responses to nursing interventions | | | |
|Evaluates and documents patient's progress towards goals | | | |
|Modifies and documents nursing interventions and patients’ goals / plan of care as needed | | | |
|*Utilizes experience, in-depth knowledge and an intuitive grasp of the patient’s condition to efficiently focus, modify and document nursing care interventions and/or the plan of care to| | | |
|address complex patient care problems | | | |
|*Proposes alternative interventions for complex patient care problems to CN I and CN II | | | |
|Patient, Family and Staff Education | | | |
|Patient and Family Education | | | |
|Identifies and documents patient/family/significant other’s educational needs and readiness to learn | | | |
| | | | |
|Provides and documents age appropriate healthcare teaching | | | |
|Evaluates and documents patient/family/significant other’s response to healthcare teaching and/or performance of return demonstration | | | |
|*Provides and documents age appropriate individualized teaching for complex healthcare educational needs | | | |
|*Assists the Clinical Nurse Specialists/designee to identify healthcare education needs | | | |
|Staff Education | | | |
|Orients float, traveler and / or registry staff to unit operations, policies, procedures, evidence based practice protocols and standards | | | |
|Teaches staff and / or students | | | |
|Precepts and mentors staff members | | | |
|*Assists in identifying staff members' learning needs | | | |
|*Shares in-depth knowledge with other staff members | | | |
|Leadership/Teamwork | | | |
| Delegates and supervises completion of appropriate tasks to licensed vocational nurses and unlicensed assistive personnel | | | |
| | | | |
| Admits, transfers and discharges patients as directed by charge nurse | | | |
| Acts as a resource | | | |
| Uses effective, respectful communication, interpersonal, and problem-solving skills to achieve desired patient outcomes and unit goals | | | |
| Engages in ongoing development of clinical knowledge | | | |
| Keeps informed of clinical / unit / organizational updates / changes | | | |
| Adheres to department attendance standards | | | |
| Complies with employment requirements, for example annual unit / department competencies, licensure, CPR & TB | | | |
| *Acts as an clinical leader by directing proficient clinical care on their assigned unit | | | |
|*Questions and evaluates current practice, promotes evidence based practice to achieve best patient outcomes | | | |
|Assumes charge responsibilities as needed: | | | |
|Provides supervision to nursing staff, unlicensed assistive personnel and supplemental staff | | | |
|Makes staffing decisions for current and oncoming shifts using the staffing matrix as a guide and approves overtime as required to maintain safe patient care | | | |
|Makes patient care assignments based on staff competencies, patient acuities, and available resources | | | |
|Coordinates and facilitates flow of patient admissions, transfers and discharges with bed control | | | |
|Ensures completion of required unit routines including, narcotic count, ER cart checklist and other unit specific tasks | | | |
|Requires ill / injured staff to have medical evaluation and complete required forms | | | |
|Interprets policy, procedures and standards and assists compliance by staff | | | |
| | | | |
|UCLA C-I-CARE/Patient Experience Practices: MY COMMITMENT TO CARE | | | |
|Observe and practice all the Service Standards listed in the “World Class Practices” (which I have read and signed) | | | |
|Practice C-I-CARE when interacting with patients, their families, visitors, or internal customers | | | |
|Connect with the patient and family members by addressing them as Mr./Ms., or by the name that they prefer | | | |
|Introduce yourself and your role | | | |
|Communicate what you are going to do, how long it is going to take, and how it will impact the patient. | | | |
|Ask and anticipate patient and/or family needs, questions or concerns | | | |
|Respond to patient and/or family questions and requests with immediacy | | | |
|Exit courteously and/or with an explanation of what will come next (or when you will be back to check on them) | | | |
|Practice C-I-CARE phone etiquette during all phone interactions | | | |
|Always exercise courtesy whenever patients, family members, visitors and co-workers are present | | | |
|Respect privacy and dignity of our patients, family members, visitors and co-workers | | | |
|Maintain professionalism in the presence of patients, their families, visitors and co-workers | | | |
|Observe departmental Patient Experience plan, competencies and practices | | | |
|Act as a role model, verbally and behaviorally demonstrating skill, enthusiasm, positive problem solving, commitment and loyalty to the profession and the organization | | | |
|Participate in positive problem solving by providing suggestions and possible solutions to identified concerns/problems in the work place | | | |
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|Comply with Health System Workplace Conduct Policy | | | |
|Engaging in disruptive behaviors that interfere with or prevent normal work functions or compromise patient safety, including passive or active behaviors will not be tolerated as stated | | | |
|in the HS Workplace Conduct Policy | | | |
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|Comply with Health System Dress Code Policy and practices | | | |
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|INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS | | | |
|Comply with HIPAA and Confidentiality Policies and Procedures as they apply to the job | | | |
|Comply with Department of Public Health (DPH), The Joint Commission and other accreditation and regulatory agencies standards | | | |
|Adhere to all Hospital Policies and Procedures | | | |
|Knowledge and adherence to Infection Control and Environment of Care Guidelines and Procedures as described in the annual education module | | | |
|Demonstrate adherence to the requirements for using the electronic medical record | | | |
|Demonstrates understanding of institutional and department specific emergency management procedures/responsibilities to maintain personal, patient, and co-worker safety, maintains | | | |
|competencies in these areas, and participates in disaster/emergency related exercises and education. | | | |
|Demonstrates understanding of institutional and department specific safe patient handling procedures/responsibilities and maintain a level of competency on the proper use of departmental| | | |
|lift equipment to ensure personal, co-worker and patient safety | | | |
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|PERFORMANCE IMPROVEMENT | | | |
|Adhere to current organizational Performance Improvement priorities | | | |
|Participate in quality studies through data collection and dashboard data collection | | | |
|Make recommendations and take actions to improve structure, system or outcomes | | | |
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|OTHER DUTIES | | | |
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|Skills, Knowledge and Abilities |
|(Disregard this section for performance evaluations) |
|REQUIREMENTS: | |
| |List any equipment (machines, tools, office appliances or motor vehicles) required to do the job, with or without a reasonable accommodation. Indicate |
| |whether use is seldom, occasional, frequent, or constant. |
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| |See Policy/Procedure Equipment Manual |
| |CPR: | | |
| |License: |RN | |
| |Certifications: | | |
| |Degree: | | |
| |Experience: | | |
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|Skills, Knowledge and Abilities: |Importance |
| |(Required or Preferred) |
| | |
|Ability to complete a Nursing physical assessment |Required |
|Skill in developing a plan of care including setting goals, monitoring and documenting progress |Required |
|Ability to implement interventions that are pertinent to goals established in the plan of care |Required |
|Ability to evaluate the effective of interventions toward the attainment of established goals and to recognize the need to reassess or reset goal |Required |
|parameters | |
|Ability to delegate tasks in a management style that is consistent with promoting leadership and teamwork |Required |
|Knowledge base to provide education to patients, families, and other staff regarding clinical and patient care issues |Required |
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|California Registered Nursing License/or CA IPRN |Required |
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|Cardiopulmonary Resuscitation Certification |Required |
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|IPRN: Active CA IPRN License | |
|CNI: Less then 6 months nursing experience | |
|CNII: Greater than 6 months nursing experience |Required |
|CNIII: Greater than 6 months recent clinical nursing experience on the unit and meets CNIII criteria |Required |
| |Required |
|If overall rating is “Does Not Meet Expectations”, please complete Future Plans and Actions Section. |
|According to the Employee Performance Evaluation Policy, an overall rating of “Does Not Meet Expectations” requires an action plan and a follow-up performance evaluation in either a three-month or six-month period |
|depending on the time needed to demonstrate improved performance. Action plan steps must be objective and measurable with a defined time frame. The date of the follow-up performance evaluation will reset the |
|performance evaluation due date. |
|Does Not Meet Expectations |Meets Expectations | |
|Comments: |
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|Future Plans and Actions: |
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|Accomplishments / Contributions: |
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|Employee Comments: |
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|To update our files, please answer the following questions: |
|Have you received a higher education degree in past 12 months: Yes______No______ |
|If Yes, in what field:_______________________________________ Type:_____________ |
|Have you received a national certification in the past 12 months: Yes______No______ |
|If yes, please list and bring a copy of certificate to Nursing Resources:__________________ |
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|Employee Signature | |Date |
|I have reviewed this Job Description and/or Performance Evaluation | | |
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|Evaluator Signature | |Date |
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|Department Head or Designee Signature | |Date |
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