Job description

To provide nursing care in accordance with the patient plan of care to include comprehensive health and psychosocial evaluation, monitoring of the patient’s condition, health promotion and prevention coordination of services, teaching and training activities and direct nursing care.

Responsibilities

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

Evaluates the effectiveness of nursing service to the patient and family on an ongoing basis.

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

Prepares and presents patient's record to the Clinical Record Review Committee as indicated.

Consult with the attending physician concerning alterations of Patient Care Plans, checks with the appropriate supervisor, and makes changes, as appropriate.

Coordinates patient services.

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

Submits a tally of patient care visits made each day

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

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

Obtains orders for paraprofessional service and submits a referral to the appropriate personnel.

Participates in the patient’s discharge planning process.

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

Participates 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.

Participates in the development and periodic revision of the physician's Plan of Treatment and processes change orders as needed.

Submits clinical notes weekly, and progress notes and other clinical record forms outlining the services rendered.

Participates in the patient’s discharge planning process.

Maintains an on-going knowledge of current drug therapy.

Adheres to Federal, state and accreditation requirements including Medicare and Medicaid regulations.

Qualifications

Must be a graduate from an accredited School of Nursing.

Must be licensed in Pennsylvania as a Registered Nurse.

One or more years of experience in community/home health agency or in a hospital setting is preferred.

Must have knowledge of Medicare and Medicaid guidelines.

Must have a working knowledge of home health care and the principles and techniques of professional nursing and required documentation that pertains to it.

Should be skillful in organization and in the principles of time management and have

knowledge of management processes.