RN - Home Health Department, FT

JOB SUMMARY

Provides direct care and instructs clients and caregivers in prevention and care of health concerns.  Comprehensively assesses clients; re-evaluates clients as needed. Develops and implements individualized care plan for each patient’s needs and revises plan as needed.  Prepares documentation. Collaborates needed changes and coordinates goals of all disciplines (such as physicians, therapists, etc.). Establishes appropriate client goals among all disciplines promoting independence through education of patient and caregivers. Demonstrates critical thinking to assure the delivery of safe, quality, age specific care. Case management of all disciplines from initial evaluation through discharge and assists in establishing appropriate community resources.  Adheres to organizational policies and procedures; regulatory accrediting body requirements; and professional practice standards, scope of practice.

PRIMARY JOB RESPONSIBILITIES

• Completes an initial assessment of patient and family to determine home care needs.  Provides a complete physical assessment and history of current and previous illness(es).
• Regularly re-evaluates patient nursing needs.
• Develops and implements individualized care plan for each patient’s needs; revises plan regularly and as needed.
• Completes charting on each patient by the beginning of each workday or within 72 hours of visit.
• Completes OASIS charting within three (3) days. 
• Uses health assessment data to determine nursing diagnosis.

• Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive and rehabilitative nursing actions.  Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures.  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 as part of the care plan development and implements prior to discharge of the patient.
• Prepares clinical notes and updates the primary physician when necessary and at least every 60 days.
• Communicates with the physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Ensures that arrangement for equipment and other necessary items and services are available.
• Instructs, supervises and evaluates home health aide care provided every two (2) weeks.

• Documents all aspects of patient care, maintains patient records and care plans in a timely manner.
• Coordinates follow-up care of client.

• Participates in on-call schedule, carries on—call phone and is available during normal business hours
• Provides patients and family members with relevant health care education and instructions regarding treatments and procedures including pre/post hospital care as appropriate.

• Maintains self-control under stressful situations and workload pressures without exhibiting negative behaviors.

• Demonstrates knowledge of disaster/emergency procedures and responds appropriately.

• Assumes responsibility and accountability for individual knowledge, skills, performance and behavior in accordance with hospital, division, and unit standards of care and policies and procedures.

• Utilizes measures to promote and maintain patient, visitor and personnel safety.

• Maintains patient, employee, physician, and organization confidentiality; respects the rights, privacy, and property of others.

• Demonstrates the appropriate use of infection control principles and personal protection equipment.

• Supports the mission, values, and vision of the organization.
• Demonstrates a positive attitude and takes the initiative to implement changes.