Provides skilled professional nursing care to the patient as prescribed by the physician and maintains compliance with regulations and standards established by CMS, CHAP; and standards of professional practice established by the State Board of Nursing, and the American Nursing Association.
Essential Job Expectations and Procedural Responsibilities:
1. Initial and ongoing comprehensive assessments of the client’s needs, including Outcome and Assessment Information Set (OASIS) assessments at appropriate time points.
2. Initiating the plan of care and revising as necessary
3. Preparing clinical progress notes
4. Coordination of services including on-call rotation, week days, weekends and holidays
5. Referral to other services as needed
6. Informing the physician and other staff of changes in the patient’s needs
7. Evaluating and appropriately documenting outcomes of care
8. Supervising LVN/LPN and paraprofessionals providing services at appropriate time frames.
9. Planning for the discharge/recert from service
10. Utilizes the Clinical Supervisor as the first resource when problems or questions occur in the field, including charting guidelines, coordination of disciplines, and supervision of home health aide services
11. Participates in quarterly utilization review and chart audits (peer and self) for OBQI/OBQM as requested by Agency
12. Follows-up timely with physician regarding lab results
Education/Experience: Graduate of an accredited School of Nursing. Current RN licensure in the State of employment. One year recent experience in Medical-Surgical care of the adult patient preferred. Two years Home Care experience preferred.