JOB SUMMARY: The Home Care Registered Nurse (RN) plans, organizes and directs home care services and is experienced in nursing with emphasis on community health education/experience.
The RN builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.
RESPONSIBILITIES: Patient Care
· Completes an initial home health assessment of patient and family to determine home care needs, and provides a complete physical assessment and history of current and previous illness(es).
· Completes initial, comprehensive and ongoing assessments of patient and family to determine hospice needs, and provides a complete physical assessment and history of current and previous illness(es).
· Conducts home visits as assigned, assessing the patient’s condition, progress toward goals, providing patient care, teaching, and other skilled interventions as ordered.
· Regularly re-evaluates patient nursing needs, as part of nursing visit.
· Initiates the plan of care and makes necessary revisions as patient status and needs change in collaboration with Case Manager.
· Uses health assessment data to determine nursing diagnosis and develops a care plan that establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions, and includes the patient and family in the planning process.
· Initiates appropriate preventative and rehabilitative nursing procedures, and administers medications and treatments as prescribed by the physician.
· Counsels the patient and family in meeting nursing and related needs.
· Provides health care instructions to the patient as appropriate per assessment and plan of care.
· Identifies discharge planning needs during nursing visits, communicates needs to team as part of the care plan development, and assists in implementing prior to discharge of the patient.
Communication
· Prepares home health clinical notes and updates the case manager and primary physician when necessary.
· Completes, maintains and submits accurate and relevant hospice clinical notes regarding patient’s condition and care given, and records pain and symptoms management changes and outcomes as appropriate.
· Prepares clinical notes and updates the primary physician and/or Medical Director (Hospice) when necessary.
· Communicates with the physician regarding the patient’s needs, and reports any changes in the patient’s condition, and obtains and receives physician’s order as required.
· Teaches the patient and family/caregiver self-care techniques as appropriate, provides medication ,diet and other instructions as ordered by the physician, and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
Works in concert with the hospice interdisciplinary group or home health interdisciplinary team.
· Communicates with community health related persons to coordinate the care plan.
· Attends home health care conference and/or interdisciplinary group meetings as requested.
Additional Duties
· Participates in on-call duties as defined by the on-call policy.
· Ensures that arrangements for equipment and other necessary items and services are available.
· Instructs, supervises, and evaluates home health care aides.
· Actively participates in quality assessment performance improvement teams and activities.
QUALIFICATIONS / REQUIREMENTS: Experience: Minimum of two years experience, at least one of which is in the area of public health, home care, or hospice nursing, is preferred Education: Graduation from an accredited school of nursing is required Licenses / Certifications: Registered nurse with current licensure to practice professional nursing in New York State, CPR certification Other: The individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials.
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