Summary:
The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.
Â
Essential Duties and Responsibilities:
- Completes an initial assessment of patient and family to determine home care needs including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points. Provides a complete physical assessment and history of current and previous illness(es).
- Regularly re-evaluates patient nursing needs.
- Initiates the plan of care and makes necessary revisions as patient status and needs change.
- Uses health assessment data to determine nursing diagnosis.
- Provides those services and/or treatments requiring substantial and specialized nursing skill.
- Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
- Coordinates services provided and makes referrals to other services as needed.
- Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.
- Counsels the patient and family in meeting nursing and related needs.
- Provides health care instructions to the patient as appropriate per assessment and plan of care.
- Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
- Acts as Case Manager when assigned by Regional Clinical Director and assumes responsibility to coordinate patient care for assigned caseload.
- Evaluate outcomes of care.
- Assign home health aide to a specific patient.
- Function as a team member demonstrating collaboration with, and responsibility to patient, physician, and interdisciplinary team.
Â
Communication
- Prepares clinical and progress notes and updates the primary physician when necessary and at least every 60 days.
- Communicates with the physician and other staff regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
- Communicates with community health related persons to coordinate the care plan.
Â
Additional Duties
- Participates in on-call duties as defined by the on-call policy.
- Ensures that arrangements for equipment and other necessary items and services are available.
- Participate in in-service programs.
- Instructs, supervises and evaluates home health aide care provided every two (2) weeks.
- Supervises LPN and paraprofessionals providing services.