To provide nursing care in accordance with the patient's plan of care to include comprehensive health and psychosocial evaluation, monitoring of the patient’s condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.
Coordinate total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the patient's condition, promoting sound preventive practices, coordinating services and teaching and training activities.
Evaluate the effectiveness of nursing service to the patient and family on an ongoing basis.
Perform admission, transfer, recertification, resumption of care and discharge OASIS for the home care patient.
Prepare and present the patient's record to the Clinical Record Review Committee as indicated.
Consult with the attending physician concerning alterations of Patient Care Plans, checks with the appropriate supervisor and makes changes, as appropriate.
Coordinate patient services.
Submit clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated.
Submit a tally of patient care visits made each day.
Participate in case conferences, discuss with the supervisor problems concerning the patients and how they may best be handled.
Discuss with the appropriate supervisor the need for the involvement of other members of the health team such as the Home Health Aide, the Physical Therapist, the Speech Therapist, the Occupational Therapist, The Medical Social Worker, etc.
Obtain orders for paraprofessional service and submits a referral to the appropriate personnel.
Participate in the patient’s discharge planning process.
Cooperate with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan.
Participate in a staff development meeting.
Continually strive to improve his/her nursing care skills by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and individual research and reading.
Participate in the development and periodic revision of the physician's Plan of Treatment and processes change orders as needed
Submit clinical notes within seventy-two (72) hours, and progress notes and other clinical record forms outlining the services rendered.
Maintain ongoing knowledge of current drug therapy.
Adhere to Federal, state and accreditation requirements including Medicare and Medicaid regulations.
May be requested by Clinical Manager to fill in for the other nurses.
Coordinates the Admission of a Patient to the Agency:
Conduct an initial and ongoing comprehensive assessment of the patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.
Obtain a medical history from the patient and/or a family member particularly as it relates to the present condition.
Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.
Evaluate the patient, family member(s) and home situation to determine what health teaching will be required.
Evaluate the patient's environment to determine what assistance will be available from family members in caring for the patient.
Evaluate the patient's condition and home situation to determine if the services of a Home Health Aide will be required and the frequency of this service.
Explain nursing and other Agency services to patients and families as a part of planning for care.
Develop and implement the nursing care plan.
May be requested by the Clinical Manager to fill in for other nurses who are on vacation or sick.
Provides skilled nursing care as outlined in the Nursing Care Plan:
Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.
The initiation of preventive and rehabilitative nursing procedures as appropriate for the patient's care and safety.
Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the patient's physical or emotional condition.
Teaching, supervising and counseling the patient and caregivers regarding the nursing care needs and other related problems of the patient at home.
Assumes responsibility for the care given by the Home Health Aide:
Supervise and evaluate the care given by the Home Health Aide as needed and at a minimum of once every 14 days.
Submit to the appropriate department/individual written evaluations of the Home Health Aides who are providing service to the patients in his/her geographical area.
Participate in periodic conferences with the Home Health Aide supervisor concerning the Aide's performance.
Chart those services rendered to the patient by the staff nurse and changes that have been noted in the patient's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the Home Health Aide, evaluates patient care and progress and closes charts of discharged patients.
Evaluate the effectiveness of her nursing service to the individual and family.
Consult with the attending physician concerning alteration of the plan of treatment in consultation with the supervisor.
Submit a tally of visits made each day.
Participate in case conferences.
Discuss with the supervisor problems concerning the patients and possible resolution.
Discuss with the supervisor the need for involvement of other members of the health team such as the home health aide, physical therapist, speech therapist, occupational therapist, social worker, etc.
Obtain orders for paraprofessional service and submits referral to appropriate personnel.
Provide guidance and supervision to the LPN and supervises the LPN once monthly.
Coordinate total patient care.
Participate in staff development meetings.
Participate in the educational experiences for student nurses.
Continually strive to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, goal setting, active participation in professional and related organizations and individual research and reading.
Participate in the planning, operation, and evaluation of the nursing service.
Participate in the development and periodic revision of the physician’s Plan of Treatment and processes change orders as needed.