The registered nurse plans, organizes and directs home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities.

Patient Care

1. 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).

2. Regularly re-evaluates patient nursing needs.

3. Initiates the plan of care and makes necessary revisions as patient status and needs change.

4. Uses health assessment data to determine nursing diagnosis. I

5. 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.

6. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician.

7. Counsels the patient and family in meeting nursing and related needs.

8. Provides health care instructions to the patient as appropriate per assessment and plan of care.

9. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.

10. Acts as Case Manager when assigned by Clinical Supervisor and assumes responsibility to coordinate patient care for assigned caseload.

Communication

1.Prepares clinical notes and updates the primary physician when necessary and at least every sixty days.

2. Communicates with the physician regarding the patienVs needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.

3. Communicates with community health related persons to coordinate the care plan.

Additional Duties

1. Participates in on-call duties as defined by the on-call policy.

2. Ensures that arrangements for equipment and other necessary items and services are available.

3. Instructs, supervises and evaluates home health aide care provided every two (2) weeks.

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