Registered Nurse Home Care VNA

Completes weekly schedule and makes scheduled home visits per assignment. Schedules and prioritizes nursing visits according to client acuity and in accordance with the organization’s emergency preparedness plan.

For each admission to caseload, develops an individualized and holistic plan of care for the patient in collaboration with the patient/family/caregiver. Performs admission physical and psycho-social assessment to determine appropriate plan of care.

For each visit, demonstrates the skills and judgment necessary to implement the plan of care, nursing interventions, and procedures necessary for the skilled care of the patient, as evidenced by chart review and observation. Updates the plan of care on an ongoing basis as goals are met and problems are identified.

For each discharge, documentation demonstrates improvement in outcomes or applicable variances are identified. Patients are appropriately prepared for discharge and all disciplines involved in the care of the patient are in agreement with plan.

Demonstrates knowledge of department policies and procedures for administering and documenting medications. Medication reconciliation is completed every visit and medication profile is reviewed and updated with changes as appropriate. DRR is run with each additional medication. Medication management is taught to each patient/family member each visit, including side effects.

The case manager demonstrates responsibility and accountability for coordinating the plan of care for each patient on caseload. The patient/family is involved and participates in the plan of care. Communicates with all disciplines to ensure quality of care.

Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. Complies with current hand hygiene and infection control guidelines.

Responds to and participates in opportunities to maintain, enhance, and promote the image of the professional nurse.

Serves in a formal or informal leadership role.

Responds to and participates in opportunities to demonstrate the use of individual advanced clinical skills and advanced clinical knowledge. Assumes overall responsibility for own professional development by incorporating knowledge of evidence-based practice and research into clinical practice.