RN - OR - Evening Shift

Performs comprehensive nursing assessment/reassessment.

• Performs age‑appropriate admission or transfer assessment.
• Accurately documents findings.
• Assesses post‑op/post‑invasive patients.
• Documents education and discharge needs.
• Reassesses patients and documents observations.

Establishes, coordinates and evaluates a plan of care based on assessment data, patient diagnosis, lab data, procedures, physician orders, protocols and other relevant information.

• Identifies short and long‑term goals.
• Forms nursing interventions.
• Incorporates evidence‑based practice.

Provides and documents nursing interventions based on assessed patient needs, plan of care, and changes in patient status.

• Collaborates with health team members.
• Coordinates and communicates patient care, including handoff reports.
• Administers medications accurately.
• Monitors IV fluids and parenteral nutrition.
• Completes referrals and requests consultations when needed.
• Provides education and discharge planning.
• Clarifies physician orders and documents “readback.”
• Manages telephone orders only in emergencies.
• Recognizes changes in patient condition and responds appropriately.
• Involves family/guardian in care and decision‑making.
• Applies infection control practices.

Documents and/or communicates nursing care and changes in patient condition.

• Evaluates effectiveness of care and documentation.
• Modifies plan of care as needed.
• Reports significant changes immediately.
• Identifies problems and suggests solutions.
• Reports variations from care/treatment per policy.

Provides specialized care to high‑risk patients.

• Restraint Care
• Initiates and evaluates restraints before application.
• Monitors patient response at intervals.
• Provides ongoing care during restraint period.
• Assesses alternatives to restraints.
• Documents restraint use thoroughly.

• Assesses pain on admission and during care.
• Incorporates cultural/spiritual beliefs into plan.
• Implements pain management techniques.
• Includes patient/family in plan development.
• Considers massage, repositioning, music therapy, etc.

• Recognizes abuse criteria in assessments.
• Reports signs to appropriate authorities.
• Supports patient safety when abuse is noted.

Demonstrates accountability for professional practice.

• Adheres to quality and performance standards.
• Engages in learning experiences.
• Maintains currency in policies and procedures.
• Adapts to changing work demands positively.

Relates professionally to coworkers.

• Orients new employees.
• Supports a collaborative team approach.
• Provides resources to staff and patients.
• Supervises and teaches students/new staff nurses.

Follows safety and infection control policies.

• Practices standard precautions and disposes hazardous waste properly.
• Maintains a safe and therapeutic environment.
• Reports risks using eSRM.
• Completes all mandatory annual requirements (licenses, immunizations, training).

Provides service excellence to patients and families.

• Demonstrates courtesy and respect.
• Communicates effectively and maintains confidentiality.
• Provides accurate handoff reports and collaborates with other departments.
• Uses resources wisely and recommends efficiency improvements.
• Maintains customer satisfaction through established principles.

Incorporates performance improvement and evidence‑based practice.

• Assists in developing unit goals and stays current with initiatives.
• Participates in performance improvement processes and data collection.
• Engages in nursing research and departmental activities.
• Contributes to quality indicator maintenance.

Provides age‑appropriate care to adults and geriatric patients.

• Applies knowledge of normal growth and development.
• Assesses and interprets age‑specific data.
• Communicates effectively with age‑specific responses.
• Involves family in decision‑making.

Delivers cost‑effective services.

• Utilizes resources efficiently.
• Recommends practice changes to reduce waste.
• Documents chargeable supplies and equipment.
• Prioritizes…