Description:

Provide nursing care to a defined group of patients, adhering to Kaiser Foundation Health Plan of Washington ambulatory Nursing Care Standards, the Nursing Code of Ethics and Kaiser Foundation Health Plan of Washington policies. Coordinate and facilitate Health Care services for the patient in other segments of the Health Care delivery system. Provide and coordinate nursing care for the patient in collaboration with the Health Care team. The Registered Nurse is an integral member of the Health Care team, overseeing and participating in patient assessment and the formulation and implementation of the care plan.

The Primary Care RN will act as a clinical resource for the team including participating in daily huddles and help solve unusual challenges. Identify and provide nursing management of high-risk patients using established criteria and protocols, coordinate multi-disciplinary team and resources to support patient care needs. Provide care coordination/management for chronic medically complex or fragile patients/patient populations using nursing protocols. This work includes the use of the nursing process, motivational interviewing, and case management skills. Incorporate preventative care into every visit and act as a patient advocate, assessing and educating patients of all ages (pediatric, geriatric, etc.) and their families. Provide nursing services needed in an outpatient setting such as medication administration, immunizations, wound care, and other nursing skilled services.

• Using the nursing process, provides ongoing assessment of the nursing care needs of a defined group of patients. Uses nursing diagnosis to describe this assessment. Develops a written plan of care for patient care needs. Assists patients and families/significant others in developing health care goals which are part of the individualized plan of care. Determines priorities of patient care based on essential patient needs and available resources. Provides nursing interventions safely and competently. Provides the patient and family/significant others with information preceding interventions. Provides telephone consultation to patients and family/significant others Provides ongoing evaluation of the patients response to care. Anticipates and recognizes changes in the patients status and need for nursing care. Modifies the individual plan of care in collaboration with the health care team.
• Demonstrates understanding of the physiologic and psychological effects of normal aging by assessing, planning, implementing and evaluating care to meet the needs of those populations served. Demonstrates effective communication skills with those specific age populations served. Identifies own learning needs and participates in educational programs related to those age-specific patient populations served (Neonatal, Pediatric, Adolescent, Geriatric). Collaborates, communicates and coordinates with other health care team members in planning and implementing care. Assesses the needs of designated patients requiring hospitalization; initiates nursing admission database and discharge planning in collaboration with inpatient staff and physician. Cooperates and communicates effectively with other team members in order to accomplish the workload.
• Communicates recognition of the patients and family/significant others psychosocial, cultural and emotional needs in each nurse-patient interaction. Orients patients and family/significant others to the role of the professional nurse and other health care team members, the nursing services available, and the means of access to those services. Reinforces orientation to the Consumer Bill of Rights and Responsibilities. Identifies the patients educational needs as part of the nursing assessment. Develops an educational component for each nursing care plan. Provides teaching/counseling congruent with patients and family/significant others learning needs and the medical plan of care. Encourages patient compliance with therapeutic and medical regimens. Teaching is based on scientific and behavioral knowledge.
• Assesses patient lifestyle risk factors. Integrates health promotion and preventive aspects of care with the ongoing assessment of nursing care needs. Works with patient to develop a plan to improve general health status. Implements physical and psychological preventive measures. Promotes patient self-care responsibility for meeting their own health needs. Adheres to KFHPW documentation standards. Provides a safe environment for each patient and adheres to KFHPW safety standards. Adheres to KFHPW infection control standards and guidelines, including the guidelines for reporting communicable diseases.
• Identifies own learning needs and participates in continued education programs to meet those needs. Participates in staff orientation and student education activities. Collaborates with managers in completing the process for self and colleague/team performance reviews. Assures quality of care through development, implementation and evaluation of professional nursing standards and participation in multidisciplinary quality assurance activities. Participates in professional activities. Participates in nursing research and incorporates research findings into nursing practice. Adheres to KFHPW personnel policies and maintains a high standard of professional work habits. Consistently demonstrates an appearance consistent with current KFHPW dress code policy.