Home Health RN: Care Coordination & Teaching

Job Overview: The Staff Nurse is a Registered Professional Nurse who administers skilled nursing care to Patients/Residents/clients requiring professional nursing service and teaches and supervises the family and other members of the nursing team. Each staff nurse performs nursing services for residents within a specific area. These services are performed in accordance with the physician's orders and under the direction and supervision of the Director of Nursing and the supervisor.

Qualifications

- Graduate of an approved school of professional nursing

- Licensed Registered Nurse in the applicable state

- Minimum of one (1) year of experience as a Professional Nurse

- A Baccalaureate degree is preferred, but may not be required

Responsibilities

Conducts the admission of the patient/Residents/client to the facility andby:

- Obtaining a medical history, particularly as it relates to the present condition, from the referral hospital,client and/or family member(s)

- Conducting a physical examination of the client, including vital signs, physical assessment, mental status, appetite and type of diet, etc.

- Evaluating the client, family member(s) and home situation to determine what health teaching will be required

- Evaluating the client's environment to determine what assistance will be available from family members in caring for the client

- Evaluating the client's condition and determine if other will be required and the frequency of this service

- Interpreting nursing and other services of the Agency to clients and families as a part of planning for care

- Preparing OASIS documents, if indicated and such other paperwork as may be required as well as implementing the nursing care plan

- Provides skilled nursing care as outlined in the nursing care plan to include the following:

• Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.
• Initiating preventative and rehabilitative nursing procedures as appropriate for the client's care and safety
• Observing signs and symptoms and reporting to the physician any reactions to treatments, including drugs, and changes in the client's physical or emotional condition
• Teaching, supervising and counseling the client and caregivers regarding the nursing care needs and other related problems of the client at home

- Is responsible for the care given by the Aide to clients in his/her care by:

• Supervising and evaluating the care given by the staff as needed and at a minimum of once every 14 days.
• Submitting to the Aide Department written evaluations of the staff who are providing service to the clients in his/her geographical area.
• Participating in periodic conferences with the Supervisor concerning the staff performance

- Charts those services the Staff Nurse has rendered to the client, changes noted in the client's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the staff evaluates client care and progress, prepares paperwork required for continuing care, and closes charts of discharged clients

- Prepares and presents client's record to the Clinical Record Review Committee as indicated

- Evaluates the effectiveness of his/her nursing service to the individual and family

- Consults with the attending physician concerning alteration of the Plan of Care in consultation with the supervisor

- Submits clinical notes no less often than weekly, and progress notes and other clinical record forms outlining the services rendered as indicated

- Submits a tally of visits made each day or as required

- Participates in case conferences

- Discusses with the supervisor problems concerning the clients and how they may best be handled

- Discusses with the supervisor the need for involvement of other members of the health team such as the Home Health Aide, Physical Therapist, Speech Therapist, Occupational Therapist, Social Worker, etc.

- Obtains orders for paramedical service and submits referral to appropriate personnel

- Coordinates total client care

- Cooperates with other agencies providing nursing or related services to provide continuity of care and to implement a comprehensive care plan

- Participates in staff development meetings

- Participates in the educational experiences for student nurses

- Continually strives to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, active participation in professional and related organizations and individual research and reading

- Participates in the planning, operation and evaluation of the nursing service

- Participates in the development and periodic revision of the physician's Plan of Care and processes change orders as needed

- Maintains an on-going knowledge of current drug therapy

- Prepares the care plan

Organizational Relationship

- Reports to Director of Nursing Services

Special Requirements

- Must have a reliable means of transportation andrequired insurance coverage and a state driver's license

- Must have valid state specific RN license

Functional Abilities

- Able to communicate verbally and in writing to the extent required by the position

- Able to physically perform the duties required by the position

- Able to travel to prospective clients' residences