The field RN is a key member of the home health care team responsible for provision of direct patient care to assigned patients and coordination of that care with other professionals. The RN establishes home health aide care plans and supervises the home health aide performing patient care. Additionally, the RN educates the patient and/or caregiver to help them obtain an optimal level of health.
- Perform initial evaluation and periodic re-evaluation of patient’s condition and recommend revisions of the patient’s plan of care as needed.
- Provide services requiring substantial and specialized nursing skill.
- Coordinate services and inform the primary physician and designated personnel of significant changes in patient’s condition and needs.
- Provide or supervise skilled nursing services in accordance with physicians orders.
- Develop, initiate, implement, and update the plan of care as needed or at least every 62 days.
- Initiate appropriate preventative and rehabilitative nursing procedures as appropriate for the patient’s care and safety.
- Counsel the patients and family in meeting nursing and related needs.
- Manage nursing and multi-disciplinary services for specific patients; including identification of needs, and referrals to other disciplines as appropriate and ordered by physician.
- Supervise the care provided by the LVN/LPN to their assigned patients.
- Prepare clinical notes in accordance with professional and agency specific standards.
- Supervise the care provided by home health aides to their assigned patients.
- Contribute to the orientation and ongoing education of other clinical personnel.
- Participate in performance improvement activities and mandatory case conferences.