Job Description Summary
The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse 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.
Essential Job Functions/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.
- Initiates the plan of care and makes necessary revisions as patient status and needs change.
- 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.
- Acts as Case Manager when assigned by Clinical Supervisor/Nursing Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
- In addition to the general competency, when the RN Case Manager is assigned to patients’ receiving palliative care services, he/she will demonstrate written competency in the following practices of palliative care as stated in the National Consensus Project “Clinical Practice Guidelines for Quality Palliative Care”
psychological and psychiatric aspects of care social aspects of care
spiritual, religious, and existential aspects of care cultural aspects of care
care of the imminently dying patient ethical and legal aspects of care
- Prepares clinical notes and updates the primary physician when necessary and at least every sixty 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.
- 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 aide care provided every two (2) weeks.
- Registered nurse with current licensure to practice professional nursing in the state.
- Graduate of National League for Nursing accredited school of nursing.
- Maintains a current CPR certification.
- Must be a licensed driver with an automobile that is insured in accordance with state/or organization requirements and is in good working order.
- Minimum of two years experience, at least one of which is in the area of public health or home care nursing is preferred.
- Self directed and able to work with minimal supervision.
- Demonstrates excellent observation, problem solving, verbal and written communication skills; nursing skills per competency checklist.
- Shows ability to organize and prioritize workload independently.
- Management experience not required. Responsible for supervising home health aides.
- Prolonged or considerable walking or standing. Able to lift, position, or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping, bending, kneeling, or crouching. Visual acuity and hearing to perform required nursing skills.