The Center is seeking a Licensed Registered Nurse to contract with who will conduct Comprehensive Nursing Assessments . The comprehensive nursing assessment must be conducted by an RN and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records. The nurse may document the source of any assessment information obtained from areas other than the nurse's assessment. The nursing assessment should be written so that it can be understood by non-medical personnel. The nurse should use acceptable medical terminology and define terms if medical abbreviations are used. The RN must indicate if any information is self-reported by an individual or LAR which is not in the clinical record, e. g., "The individual stated he has a history of…"
When conducting the comprehensive nursing assessment, the individual's privacy must be respected and should be done in a private environment away from anyone who does not need to be included as part of the nursing assessment. If appropriate, an individual's family/LAR or staff may be included for a portion or all of the nursing assessment to help gather information. The individual should always be consulted first and the nurse should ask who else the individual wants to participate.
For any abnormal condition, describe the abnormal condition in the Comments section of the related item. Any additional findings or important information that is not listed on the comprehensive nursing assessment should be documented in the Comments section.
The contractor must complete Comprehensive Assessments, and submit to the Program Director or designee within 10 Center business days along with all testing materials, booklets, score sheets, etc. The contractor must ensure that documentation of service (HHSC Form 2122) for each individual with a minimum of 5 billable hours is completed and submitted within 10 Center business days. The contractor will ensure that credentialing standards are met, including licensure maintained and updated annually without lapse. All required Center classroom and online training must be completed upon contract execution, and updated annually. The contractor will need to submit to criminal history background check and Nurses "Abuse/Neglect" registry, or other checks as required by the Center.