The advanced practice provider (Nurse Practitioner/Physician Assistant) within the acute care hospital setting works in collaboration with, and is an integral member of, a multidisciplinary health care team. The APP provides comprehensive care on the inpatient Hospital Medicine service.

Assessment & Management

• Performs complete history & physicals and documents in the medical record.
• Orders and collects data using appropriate assessment techniques, relevant supporting diagnostic information and diagnostic procedures where indicated.
• The APP may serve as the first responder for both nursing and house staff in the event of patient status changes, orders, and in situations requiring procedural and resuscitative interventions.
• Assesses for risks associated with the care of the acute and complex chronically ill patient including: medication side effects, immobility, impaired nutrition, fluid and electrolyte imbalance, immunocompetence, invasive interventions and diagnostic procedures.

Diagnosis

• Collaborates with interdisciplinary health care team in making diagnoses of acute and complex chronic conditions.
• Manages diagnostic tests through ordering, interpretation, performance, and supervision.
• Formulates differential diagnoses by priority.
• Diagnoses complications and orders appropriate interventions

Formulates Plan of Care

• Identifies expected outcomes from diagnosis, and formulates and documents a plan of care to address complex acute and chronic health care needs.
• Utilizes evidenced based practice guidelines and protocols in an individualized, dynamic plan of care that can be applied across the continuum.
• Implements and modifies plan of care.
• Prescribes diagnostic strategies and therapeutic interventions.
• May perform advanced procedures consistent with privileges and competency validation.

Communication and Collaboration

• Maintains ongoing communication and collaboration with interdisciplinary health care team.
• Facilitates and communicates with patient, family and staff to promote continuity of care across the inpatient and outpatient continuum of care.

Documentation

• Documents/dictates key components of patient's progress via daily progress note, transfer, and discharge summary, and or clinic note where applicable. (h&p, daily progress notes, plan of care, problem lists, procedure notes, acute event note, discharge summaries, in medical record per specific patient unit or service, death summary)
• Documentation is timely, meets acute care compliance standards and captures patient acuity.

Professional Practice

• Demonstrates Professional Practice behaviors including: preceptor/mentoring, education and instruction of graduate students.
• Seeks opportunities for active engagement in research and the analysis of evidenced based practice.
• Actively participates in Advance Practice Grand Rounds and specialty specific meetings.
• Maintains CEUs, and membership in a professional organization.