REGISTERD NURSE

Job Description

Job Description

Coordinate total patient care by conducting comprehensive health and psychosocial evaluation, monitoring the patient's condition, promoting sound preventive practices, coordinating services, and teaching and training activities

Evaluate the effectiveness of nursing service to the patient and family, on an ongoing basis

Perform admission, transfer, re-certification, resumption of care, and discharge paperwork for the home care patient.

Prepare and present patient’s record to the Clinical Record Review Committee, as indicated

Consult with the attending physician concerning alterations of Patient Care Plans, check with the appropriate supervisor and make changes, as appropriate

Coordinate patient services

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

Submit a tally of patient care visits made each day

Participate in case conferences, discuss, with the supervisor, problems concerning the patients and how they may best be handled

Discuss, with the appropriate supervisor, the need for the involvement of other members of the health team such as the Home Attendant, the Physical Therapist, the Speech Therapist, the Occupational Therapist, The Medical Social Worker, etc.

Obtain orders for paraprofessional service and submit a referral to the appropriate personnel

Participate in the patient’s discharge planning process

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

Participate in staff development meeting

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

Participate in the development, and periodic revision, of the physician's Plan of Treatment and process change orders, as needed

Maintain an on-going knowledge of current drug therapy

Adhere to federal and state requirements

May be requested, by Director of Nursing, to fill in for the other nurses

Conduct an initial, and ongoing, comprehensive assessment of the patient’s needs, at appropriate time frames

Obtain a medical history from the patient, and/or a family member, particularly as it relates to the present condition

Conduct a physical examination of the patient, including vital signs, physical assessment, mental status, appetite and type of diet, etc.

Evaluate the patient, family member(s), and home situation to determine what health teaching will be required

Evaluate the patient's environment to determine what assistance will be available from family members, in caring for the patient

Evaluate the patient's condition, and home situation, to determine if the services of a Home Attendant will be required and the frequency of this service

Explain nursing, and other Agency, services to patients and families, as a part of planning for care

Develop, and implement, the nursing care plan

Prepare the care plan for the Home Attendant

Supervise, and evaluate, the care given by the Home Attendant, as needed, as per Agency policy

Submit, to the appropriate department/individual, a written evaluation of the Home Attendants who are providing service to the patients, in his/her geographical area

Participate in periodic conferences, with the Home Attendant supervisor, concerning the Aide's performance

Chart those services rendered to the patient, by the staff nurse, and changes that have been noted in the patient's condition and/or family and home situation, make revisions in the nursing care plan, as needed, record supervisory visits conducted with the Home Attendant, evaluate patient care and progress, and close charts of discharged patients

Obtains orders for paraprofessional service and submits referral to appropriate personnel

Contact with clients under a wide variety of circumstances

Care is provided in client’s living environment with varying situations, including private homes, independent or assisted living or in an institution such as a hospital or long-term care facility.

May be required to respond to emergency situations.

Position includes tasks that have the potential for exposure to blood/body fluids/tissues and other potentially infectious material such as body fluids/tissues.