Entry Level Rn Data Abstractor Jobs in Poughkeepsie, NY

The Registered Nurse demonstrates competence by integrating theoretical knowledge with clinical experience in the care of assigned patients and families by independently assessing, planning, and evaluating patients and families utilizing the systematic approach of the Nursing Process.  The RN utilizes patterns of patient responses to guide practice and provides nursing care as defined by the ANA Scope and Standards of Practice, in accordance with the objectives, policies and procedures of MHVS, the NY State Nurse Practice Act and our Philosophy of Nursing.  

RESPONSIBILITIES:

Clinical Skills and Knowledge

• Completes a thorough patient assessment addressing all pathophysiologic and psychosocial needs.
• Identifies key nursing diagnosis from the assessment data.
• Prioritizes nursing diagnoses with consideration of cultural/religious/spiritual needs. 
• Establishes data-driven individualized plan-of-care. 
• Implements individualized plan-of-care/discharge plan including coordination with other disciplines utilizing clinical experience as a guide.
• Utilizes critical thinking skills in adapting plan-of-care in response to changes in patient needs.
• Evaluates outcomes of plan-of-care and alters plan as needed.
• Recognizes and intervenes in situations related to patient safety.
• Organizes and prioritizes work assignments based on the patient needs and acuity.
• Demonstrates ability to make effective nursing judgments.
• Documents patient’s progress legibly and in a timely manner. 
• Documents nursing interventions and patient responses in accordance with hospital policy.

Communication /Collaboration:

• Advocates for patient well being (i.e., religious /culture preferences, privacy, etc.)
• Communicates patient data in clear, concise and timely manner both in written and verbal form.
• Individualizes communication based upon assessment of patient/family.
• Identifies and evaluates the patient’s and family’s learning needs, abilities and readiness to learn – teaches and documents appropriately.

Management of Care/Leadership:

• Delegates and supervises patient care appropriately.
• Functions as a charge nurse according to protocol. Assists nurse manager in performance appraisals.
• Participates in unit based QI projects. Initiates a unit specific project related to clinical care of the patients.
• Manages patient care within assigned time frames.
• Actively participates in coordination of care on the unit. Willingly floats to other areas of hospital.

Professional Development:

• Functions and upholds the professional standards of the registered nurse role via evidence-based practice, interactions and appearance. Identifies potential areas of nursing research. Assists with Nursing Research projects. Helps participate in orientation and precepting of staff as needed.
• Accepts accountability for own practice. Identifies potential learning needs of staff.

Quality Improvement and Safety:

• Administers medications safely including:  preparation, pre and post assessment, and monitoring of patient’s responses. 
• Promotes a culture of safety by fostering an attitude of trust, participation and collaboration among colleagues.
• Identifies potentially dangerous situations to his/her manager which could cause medical error/patient or staff harm and takes action, where appropriate to minimize risk of injury.
• Reports errors, documents appropriately.

Performs other related duties as required

EXPERIENCE:

• Graduate Nurse considered

EDUCATION:

• Graduate of an accredited school of nursing.

LICENSES/CERTIFICATIONS:

• Current licensure in New York State as a Registered Professional Nurse.
• Certified in Basic Life Support. 
• Other certifications as required in specialty area.

OTHER:

• If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
• Must possess excellent customer service skills. 
• Must demonstrate ability to communicate effectively verbally and written. 
• Must demonstrate ability to form effective working relationships with hospital personnel of all levels, to include the multidisciplinary team and both patients and families.