In coordination and collaboration with the assigned Clinical Team Manager, is responsible for providing skilled nursing care to patients and their families. Coordinates care with other members of the home care team; supervises Home Health Aides. The majority of patient visit time is devoted to patient evaluations, admissions, and informational visits.
AREAS OF RESPONSIBILITY:
- Performs an initial, comprehensive assessment.
- Documents observations, clinical findings, problems, skilled interventions, goals and discharge plans
- In consultation with the assigned Clinical Team Manager, initiates and regularly re-evaluates and revises the plan of care.
- Assesses the need for the services of other team members (PT, OT, ST, MSW, and HHA).
- Provides and documents skilled care on all visits (includes skilled observation of the patient’s condition, skilled care, and procedures and teaching of the patient and/or family).
- Obtains and documents physician orders.
- Performs Home Health Aide supervisory visits per regulatory requirements.
- Coordinates care with the assigned Clinical Team Manager, physician and other members of the home care team, informing them of significant changes in the patient’s condition and needs. Documents these communications.
- Follows established standards for point of service technology, documentation, and synchronization.
- Submits weekly visit schedule of assigned patients. Collaborates with Clinical Team Manager to address scheduling needs.
- Performs re-certifications, resumption of care, transfers, and discharges as requested by the assigned Clinical Team Manager. Completes and submits all related documentation.
- Attends and actively participates in the clinical team multidisciplinary patient conference.
- Demonstrates established clinical competencies.
- Participates in agency sponsored in-service education.
- Participates in quality improvement activities.
- Assists in development of agency protocols, procedures and policies as requested.
- Assesses, develops, organizes and delivers teaching materials for assigned home care patients as appropriate.
Current California RN license.
Current CPR Certificate.
Minimum of one year of nursing experience required.
Current California driver’s license and automobile insurance.