The Registered Nurse is a member of the interdisciplinary team working in collaboration with the Physician. The Registered Nurse utilizes the nursing care process consistent with their license and/or certification including initiation of culturally competent continuum of care including inpatient, outpatient and community settings. The Registered Nurse is responsible to oversee any necessary coordination of the interdisciplinary plan of care and provides for its consistency with the medical treatment plan. The patient care process includes:
* Assessment - an orderly process consisting of the identification, gathering and organization of subjective and objective data pertaining to the patient/family/significant other, including physical, psychosocial, spiritual and cultural.
* Planning - an organized step in the process that consists of the identification of actual or potential problems and desired outcomes (goals) that result in a documented plan of care. The plan of care provides direction for the patient/family/significant other and interdisciplinary team.
* Intervention - the specific interventions or orders that are implemented consistent with the plan of care and medical treatment plan.
* Evaluation - a step in the process that involves determining the effectiveness of the interventions in achieving the plan of care and determining the conclusions concerning the achievement or lack of achievement of desired outcomes. The evaluation may initiate the need for reassessment and revisions to the problems, goals, plan of care, and interventions. This step provides for documentation of required actions. Based upon findings identified during assessment and reassessment:
* Patients have problems identified and prioritized relative to biophysical, psychological, environmental, self care, educational and social status.
* Goals are identified consistent with the problem to provide direction for patient care and health promotion.