Provides coordinated skilled nursing care to patients of all age groups, on an intermittent basis in the home. Demonstrates accountability and responsibility in collaborating with the interdisciplinary team to establish and achieve patient goals and maintain high quality patient care. Performs in accordance with physician’s orders and under the supervision of the Director, Clinical Services.
- Assesses home health patients identifying physical, psychosocial and environmental needs as evidenced by documentation, clinical records, case conferences, team reports, call-in logs and on-site evaluations.
- Completes OASIS, assessment and visit paperwork according to agency policy. Assures clinical notes accurately indicate continuing communication and coordination of services with the physician, other interdisciplinary team members and patient/family/caregiver.
- Communicates significant findings, problems and changes to Director, Clinical Services and physician, and documents all findings, communications, and appropriate interventions.
- Demonstrates knowledge and proficiency in identifying, reporting and documenting problems, adverse reactions or possible complications related to patient care. Recognizes and reports life threatening situations and responds appropriately. Recommends and incorporates other disciplines in the care of the patient, as needed, and under the direction of the referring physician.
- Participates in the development and implementation of the Plan of Care (POC) to ensure quality and continuity of care and appropriate discharge planning. Establishes Plan of Care in coordination with the physician, patient, family and interdisciplinary team members. Incorporates long and short term goals established in the Plan of Care into nursing care, as evidenced by documentation in visit notes.
- Supervises and provides clinical direction to home health aides and LPNs/LVNs to ensure quality and continuity of services provided.
- Participates in interdisciplinary patient care conferences and Agency Performance Improvement processes.
- Receives referrals from physicians, hospitals, clinics, patients, families and other agencies when needed and notifies agency personnel on a timely basis.
- Assures the continuity of patient care and coordination of services through delivery of quality patient care. Performs in a manner that is consistent with current standards of practice and with the Agency’s policies and procedures. Follows all infection control and universal precautions guidelines/standards per agency policy.
- Responsible for participating in on-call rotation and emergency call according to agency policy.
- Demonstrates commitment, professional growth and competency. Strives to continually improve nursing knowledge base through individual research, reading, attendance at workshops/professional conferences and professional organizations.
This job description represents an overview of the responsibilities for the above referenced position. It is not intended to represent a comprehensive list of responsibilities. An associate should perform all duties as assigned by his/her supervisor.