RN2 Individual Performance Plan

1.

MANAGEMENT & LEADERSHIP OF DIRECT CARE STAFF

OUTCOME:Daily, direct, supervise, evaluate and counsel direct
care staff by assigning and monitoring patient care throughout
the assigned shift, and by following the hospital nursing policies
and procedures manuals on TDMHSAS Intranet site that govern
patient care to assist in providing a therapeutic and safe
environment.
Action Steps:
1.
Throughout shift, will complete an assignment sheet for
technicians and nurses, will monitor and perform RN
supervisory rounds on the unit throughout the shift to
ensure that LPNs and Psychiatric Technicians are
performing assigned tasks and will encourage completion
of tasks when necessary.
2.
Demonstrates the ability to solve problems in order to
meet the needs of the individual with whom interaction is
taking place.
3.
All required documentation and paperwork is completed
according to facility policy and procedure. (Nurs. P&P
803,1017,804,1014,201)
4.
Consistently promotes and supports strict adherence to
policies and procedures as outline in departmental
policies/procedures and Infection Control Manual. (P&P
1015.01)
5.
Communicates pertinent information regarding patients on
the shift report to staff, nurse manager/nursing supervisor,
RN 4, and Nurse Executive.

2.

COMMUNICATION AND DOCUMENTATION

OUTCOME: Daily, and throughout assigned shift, share
information with hospital staff to assist in providing a therapeutic
and safe environment for patients and staff by verbal and/or
written communication according to Hospital/Nursing Policies and
Procedures to include but not limited to the following:
Change of Shift Reports
Incident Reports
Treatment Team Meetings
Progress Notes
Medication Errors

Forms Related to Unexpected Occurrences

Verbal Notification to Supervisor of Unexpected Occurrences
Census reports
RN2 Individual Performance Plan (Continued)
Action Steps:
1.
Documents pertinent information according to MTMHI
policy and procedure, (daily, weekly, monthly patient
charting, treatment plans, incident reports, medication
orders/administration, group notes, reports, assignments).
(Nurs. P&P 1014, 808, 1013, 803, 1017, 1012, 201)
2.
Communicates pertinent information regarding patients on
the shift report to staff, nurse manager, nursing supervisor,
PNS/RN 4, and Nurse Executives.
3.
Throughout shift, communicates with patients and their
family members, other staff, and community members in a
clear and positive manner.
4.
Demonstrates the ability to solve problems in order to
meet the needs of the individual with whom interaction is
taking place.
5.
Consistently demonstrates willingness and ability to
communicate positively and effectively with others to get
needs met across a variety of situations.
6.
Follows HIPPA rules when interacting with others to discuss
patient issues. (P&P 0401.01)
7.
Always communicates assessment data and findings with
other members of the treatment team and staff.
8.
Functions as group leader for Treatment Mall groups and
documents patient group notes.
3.

MEDICATION ADMINISTRATION
OUTCOME: Transcribe, prepare and manually administer
medications according to physicians orders and facility
Medication Administration Policy and Procedures and document
on Medication Administration Record (MAR) and if appropriate, in
progress notes of patients record to assist in enhancing patients
movement toward recovery and discharge.
Action Steps:
1)
Prepares and administers medication accurately and
appropriately, according to policies and procedures. (Nurs.
P&P 803, 807, 808)
2)
Utilizes two patient identifiers
to insure safely
administering medications, (patient picture, patient

3)
4)

armband, asking familiar staff to identify, asking patient to

identify themselves).
Maintains accountability and security of scheduled drugs
according to policies and procedures. (Nurs. P&P 808)
Accurately identifies and reports to physician patient
medication requests, side effects, and adverse reactions to
medications.
RN2 Individual Performance Plan (Continued)

5)
6)
7)

4.

Accurately reports medication errors to physician according

to policies and procedures. (Nurs. P&P 808, 807, 1012)
Utilizes appropriate policy and procedure for obtaining
medications after pharmacy hours. (Nurs. P&P 803)
Documents according to policies and procedures, regarding
first dose medications, PRN medications, medication
effectiveness, and adverse reactions to medications. (Nurs.
803)

ADMISSIONS/TRANSFERS / DISCHARGES/LEAVES
OUTCOME: Immediately upon receipt of patient referral, begin
the assigned admission tasks according to MTMHI Admission
Nurse Checklist and Admission Policies and Procedures to assist
in preparing patient for escort to assigned unit.
Immediately upon receipt of verbal or written notification from
physician, performing duties as listed on the Patient Discharge
Form, completing the Nursing Section of the Discharge/Aftercare
Plan and updating the patients status information for immediate
input into the AVATAR
System to facilitate patient
discharge/leave processing.
Action Steps:
1)
Will ensure that all required documentation for patients
admission/discharge/leave, is completed per MTMHI policy
and procedure. (Nurs. P&P 201)
2)
Will complete Nursing Assessment for each new
admission/transfer within 24 hours of admission. Will
document justification for non-completion of Nursing
Assessment Q. 24 hours, according to policy and
procedure. (Nurs. P&P 201)
3)
Will provide appropriate notification to all departments
regarding patients admission/transfer/leave/discharge.