AREAS OF RESPONSIBILITIES
1. Provides individualized skilled Nursing care to the patients requiring part-time intermittent professional nursing service through the use of the nursing process.
2. Provides assessment of patient and develops a plan of treatment and care with ongoing evaluation of patient/family needs for other services.
3. Provides professional nursing services as outlined in the patient's plan of treatment and authorized by patient's physician, and provides emergency treatment as needed.
4. Records physical, social, psychosocial and environmental needs of the patient. Provide ongoing monitoring of the patient in the home care setting and escalates any clinical changes to the physician or non-physician provider as needed.
5. Utilizes input from patient, caregiver, MD and peers to devise a Nursing Care Plan which is feasible within the physical, financial and emotional resources of the patient/caregiver and the Department of Health (DOH) regulations.
6. Evaluates patient's response to plan of care (POC) as necessary, consistent with physician's orders.
7. Reviews and revises plan of care as necessary, consistent with physician's orders.
8. Plans activities necessary for effectuating the timely discharge/transfer of patient, and notifies all appropriate parties including patient's physician.
9. Authorize & coordinate all services including nursing, rehab, respiratory therapy, nutritional services, equipment, professional and non-professional staffing and support services.
10. Collaborates with case managers and other disciplines regarding the patient’s progress and discharge plans.
11. Demonstrates a professional attitude and ethical conduct in compliance with departmental standards.
12. Involves the patient and caregiver actively in goal setting.
13. Establishes and maintains a cooperative, effective working relationship with the staff, physician and non-physician providers, Case Managers and other hospital personnel, outside vendors, agencies and the community at large.
14. Attends weekly to bi-monthly team meetings and participates in case conferences and case load reviews on a weekly to bi-weekly basis.
15. When needed completes Physician’s Orders in a timely manner.
16. Completes admission paperwork, including OASIS, Physician and Nursing POCs and progress notes within 48 hours of visit encounter.
17. Reviews clinical records to ensure compliance with departmental and regulatory standards.
18. Obtains written orders for all verbal orders returned.
19.Maintain up-to-date patient files with complete records including care plans and re-certifications, reports ofall services rendered, progress notes and discharge summaries.
20.Writes clean and concise progress notes that reflect the implementation of the plan of care and the patient’sresponse to that plan of care.
21.Competent in knowledge of patient teaching plans and interventions.
22.Competent in knowledge of safe administration and teaching medications.
23.Demonstrates safety and accuracy in performing treatments and procedures according to the Home CareDepartment standards of care/practice.
24.Competent to complete thorough and accurate nursing assessments.
25.Demonstrate competence in skilled nursing interventions.
26.Competent in knowledge of documentation requirements for Home Care.
27.Participates in case conferences and/or Interdisciplinary Team conferences as needed and as designated bythe Clinical Manager.
28.Works with other members of the Interdisciplinary Team to develop appropriate interventions in order toachieve clinical and functional goals.
29.Participates in the agency’s Quality Assurance Performance Improvement/Performance Improvement Plan(QAPI/PIP) as assigned.
30.Supervises and monitors the care given by home health aides and ensures proper documentation.
31.Participates in an interdisciplinary health care team in determining and implementing a comprehensive planof care.
32.Participates in the coordination of other professional and para-professional services in the home andprovides supervision as needed and per DOH regulations.
33.Provides patient/family/significant other/patient identified representatives with teaching and involves them inassessment activities and goal setting.
34.Maintains current, complete, and appropriate documentation in the patient care record. May be required touse computer systems in carrying out these functions.
35.Duties include but may not be limited to wound care, including NPWT/VAC, Peg/Trach Care Management,Foley insertion and catheter care management, JP/PleuRx Drain care, administering injections.
36.Provides teaching on disease and medication management.
37.Obtains photographs for consultation by wound specialists.
38.Ability to apply evidence-based practices to the home care setting.
39.And other duties as ordered/prescribed.