Job Description

• 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.

 

Communication:

• 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.

 

Additional Duties:

• 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.

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