Registered Nurse

KEY

JOB RESPONSIBILITIES:

Able to complete initial and ongoing comprehensive assessments of patient’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.

Develops, implements and evaluates the patient’s plan of care that is congruous with the physician’s orders through assessment of patient’s needs, condition, environment and consultation with other health team members.

Collects accurate OASIS data at time appropriate periods.

Verbalizes and demonstrates understanding of the medication reconciliation process. This includes verification and validation of all medications (prescription and non-prescription) the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.

Provides appropriate documentation of follow-up with the patient’s physician to resolve any medication discrepancies and/or report significant findings.

Verbalizes and demonstrates understanding of issuing both the verbal and written notice of the patient’s rights and responsibilities and the agency’s transfer and discharge policy.

Able to adequately assess and reassess pain. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.

Provides patient with the required written information:
Visit schedule, including frequency of visits; patient medication schedule/instructions; which medications will be administered by the nurse; any treatments; any other pertinent instruction/s; and any new orders/treatments with date.

Demonstrates knowledge of medications and their correct administration, follows the seven (7) medication rights to reduce the potential for medication errors. (Right: patient; medication; dose; route; time; documentation; reason)
Provides skilled nursing care.

Documents wound measurements with each comprehensive assessment and weekly thereafter.

Performs all aspects of patient care in an environment that optimizes patient safety, quality and reduces the likelihood of medical/health care errors.

Patient’s plan of care is re-evaluated and updated as necessary.

Initiates needed referrals to other disciplines and/or community resources.

Notifies the physician with changes in the patient’s status, orders obtained are documented as well as any follow-up, (Example: obtaining lab orders, results and notifying physician).Verbalizes and demonstrates understanding of care coordination among all disciplines assigned to the patient, including the home health aide, to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, discharge planning, etc.

Promotes patient/family education using various verbal and written communication techniques that consider the patient’s/family’s cultural, ethnic and/or personal needs or preferences.

Obtains needed supplies and equipment to provide care.

Supervises Home Health Aides no less frequently than every 14 days.

Monitors and evaluates LPN’s performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient’s status and health needs as delegated by the RN.Performs admission assessment within 48 hours of referral, or 48 hours of patient’s return to his/her residence, or on the physician-ordered start of care date. Documents reason for delay in admission assessment.

Submits documentation in a timely manner per Agency policy: OASIS assessments are to be submitted within 48 hours and visit notes are to be submitted by 10:00AM on the Monday following the visit.

Notifies the Intake…