Completes an initial, comprehensive and ongoing comprehensive assessment of patient and family to determine home health needs. Provides a complete physical assessment and history of current and previous illness(es).
Provides professional nursing care by utilizing all elements of nursing process and as defined in the state Nurse Practice Act.
Assesses and evaluates patient’s status by:
Writing and initiating plan of care
Regularly re-evaluating patient and family/caregiver needs
Participating in revising the plan of care as necessary
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 that establishes goals, based on nursing diagnosis and incorporates palliative 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 in the physician’s plan of care.
Counsels the patient and family in meeting nursing and related needs.
Provides health care instructions to the patient as appropriate per assessment and plan.
Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.
Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.
Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
Communicates with community health related persons to coordinate the care plan.
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 interdisciplinary group.
Provides and maintains a safe environment for the patient.
Assists the patient and family/caregiver and other team members in providing continuity of care.
Works in cooperation with the family/caregiver and home health interdisciplinary group to meet the emotional needs of the patient and family/caregiver.
Attends interdisciplinary group meetings.
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.
Supervises ancillary personnel and delegates responsibilities when required.
Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and inservice classes.
Fulfills the obligation of requested and/or accepted case assignments.
Actively participates in quality assessment performance improvement teams and activities.
Graduate of an accredited school of nursing. One (1) to two (2) years of recent acute care experience in an institutional setting, and one (1) to two (2) years of recent experience in home care.
Current licensure in State and CPR certification.
Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order.
Bachelor’s degree, with one (1) year of home health care experience preferred.
Management experience not required. Responsible for supervising home health aides.
Excellent observation, verbal and written communication skills, problem solving skills, basic math skills; nursing skills per competency checklist.
Prolonged or considerable walking or standing. Able to lift, position and/or transfer patients. Able to lift supplies and equipment. Considerable reaching, stooping bending, kneeling and/or crouching. Visual acuity and hearing to perform required nursing skills.