Field Registered Nurse - Home Health - Per Diem​/Req

job objective

to provide, supervise and coordinate skilled nursing care, personal care and other services given to her/his assigned patients. The registered nurse (rn) performs the comprehensive patient assessment, develops plan of care, oversees the execution of plan of care, ensures care is provided as ordered in the plan of care, delegates nursing services to home health aides (chha) and licensed vocations nurses (lvn) and provides skilled nursing care.

a.
patient care

• acts as the patients advocate and protects patients’ confidentiality.
• distributes and explains patient’s rights and responsibilities.
• demonstrates knowledge regarding special needs and behaviors of age specific groups and demonstrates proficiency in age specific competencies.
• demonstrates knowledge of medical disease processes, surgical procedures, psychosocial behavior, and nursing care theory and practice.
• provides the initial nursing assessment on patients involving physical, physiological and psychosocial status. This assessment should include therapeutic regimen and environmental factors involved in the patient’s care.
• performs patient care according to plan of care and md orders.
• counsels and instructs patients and caregivers in meeting nursing and related needs.
• coordinates care with physicians and other disciplines involved through collaboration with other agency staff and participation in case conferences.
• encourages and moves patients/caregivers towards self-management of patient’s care.
• initiates a plan of treatment and makes necessary revisions based on nursing assessment. The plan of care is established based on collaboration with patients, caregivers and physicians. Establishes appropriate goals and discharge plan. Established and revised plan of treatment in accordance with physician orders. Routinely re-evaluates plans of treatment and updates as needed.
• utilizes best practices as available in all aspects of patient care.
• utilizes disease management programs once established.

b.
communication

• able to communicate effectively while maintaining good working relationships with co-workers, managers and office staff.
• acts as a resource for patients to ensure understanding and compliance of the assessment plan.
• participate in interdisciplinary case conferences, in-service programs, and committee meetings.
• communicates to case manager, physicians and/or director of patient care services changes in the patient condition and needs.

c.
documentation

• prepares complete, concise and clear documentation of nursing interventions, goals, patient’s response to treatment, changes in patient condition and coordination with other services.
• all documentation is completed timely within agency policies.
• effective oral and written communication skills for reporting and recording clinical findings.

d.
education

• participates in age specific educational and training programs.

e.
case management

• responsible for the overall planning, ongoing care, and discharge planning of the patient’s care.
• responsible that the patient’s plan of care meets all regulations, and that payment is authorized when necessary.
• responsible for notifying physicians of changes to the plan of care and/or barriers to plan of care.
• responsible for communication with other disciplines as appropriate.
• responsible for maintaining an accurate schedule per agency process, including appropriate clinical needs i.e. Labs etc., completing or assigning recertification within cms requirements, and scheduling supervision of chha/lvn.
• responsible for reporting patient’s care, progress and barriers to plan of care in case conferences and as needed to dpcs.
• responsible for appropriate follow up to patient’s labs as appropriate.

f.
supervision

• responsible for supervision of chha by establishing chha plan of care, performing and documenting chha supervisory visits every 14 days, and updating the chha plan of care as needed.
• responsible for supervision of lvn by overseeing patients’ care, communication with lvn, updating the plan of care as needed, performing and documenting lvn supervisory visits every 30 days.

non-essential duties:

• participates in quality improvement (qapi) process as…