TITLE OF POSITION: REGISTERED NURSE

TITLE OF IMMEDIATE SUPERVISOR: Director of Clinical Services

RISK OF EXPOSURE TO BLOODBORNE PATHOGENS - HIGH

DUTIES

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

RESPONSIBILITIES

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

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

3. Performs admission, transfer, re-certification, resumption of care and discharge paperwork for the home care client.

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

5. Consults with the attending physician concerning alterations of Client Care Plans, checks with the appropriate supervisor and makes changes, as appropriate.

6. Coordinates client services.

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

8. Submits a tally of client care visits made each day.

9. Participates in case conferences, discusses with the supervisor problems concerning the clients and how they may best be handled.

10. Discusses with the appropriate supervisor the need for the involvement of other members of the health team.

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

12. Participates in the client’s discharge planning process.

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

14. Participates in staff development meeting.

15. Continually strives 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.

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

17. Submits clinical notes within seventy-two (72) hours, and progress notes and other clinical record forms outlining the services rendered.

18. Participates in the client’s discharge planning process.

19. Maintains an on-going knowledge of current drug therapy.

20. Adheres to Federal, state and accreditation requirements.

21. May be requested by Director of Clinical Services to fill in for the other nurses.

COORDINATES THE ADMISSION OF A CLIENT TO THE AGENCY

1. Conducts an initial and ongoing comprehensive assessment of the client’s needs at appropriate time frames.

2. Obtains a medical history from the client and/or a family member particularly as it relates to the present condition.

3. Conducts a physical examination of the client, including vital signs, physical assessment, mental status, appetite and type of diet, etc.

4. Evaluates the client, family member(s) and home situation to determine what health teaching will be required.

5. Evaluates the client's environment to determine what assistance will be available from family members in caring for the client.

6. Evaluates the client's condition and home situation to determine if the services of a paraprofessional will be required and the frequency of this service.

7. Explains nursing and other Agency services to clients and families as a part of planning for care.

8. Develops and implements the nursing care plan.

9. May be requested by the Director of Clinical Services to fill in for other nurses who are on vacation or sick.

PROVIDES SKILLED NURSING CARE AS OUTLINED IN THE NURSING CARE PLAN

1. Nursing services, treatments and preventative procedures requiring substantial specialized skill and ordered by the physician.

2. The initiation of preventative and rehabilitative nursing procedures as appropriate for the client's care and safety.

3. Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, as well as changes in the client's physical or emotional condition.

4. Teaching, supervising and counseling the client and caregivers regarding the nursing care needs and other related problems of the client at home.

ASSUMES RESPONIBILITY FOR THE CARE GIVEN BY THE PARAPROFESSIONAL

1. Supervises and evaluates the care given by the paraprofessional as per agency policy.

2. Submits to the appropriate department/individual a written evaluation of the paraprofessional who is providing service to the clients in his/her geographical area.

3. Participates in periodic conferences with the paraprofessional supervisor concerning the employee’s performance.

4. Charts those services rendered to the client by the staff nurse and changes that have been noted in the client's condition and/or family and home situation, makes revisions in the nursing care plan as needed, records supervisory visits conducted with the paraprofessional, evaluates client care and progress and closes charts of discharged clients.

5. Evaluates the effectiveness of her nursing service to the individual and family.

6. Consults with the attending physician concerning alteration of the plan of treatment in consultation with the supervisor.

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

8. Submits a tally of visits made each day.

9. Participates in case conferences.

10. Discusses with the supervisor problems concerning the clients and possible resolution.

11. Discusses with the supervisor the need for involvement of other members of the health team such as the paraprofessional.

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

13. Provides guidance and supervision to the LPN and supervises the LPN per agency policy.

14. Coordinates total client care.

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

16. Participates in staff development meetings.

17. Participates in the educational experiences for student nurses.

18. Continually strives to improve his/her nursing care by attending in-service education, through formal education, attendance at workshops, conferences, goal setting, active participation in professional and related organizations and individual research and reading.

19. Participates in the planning, operation and evaluation of the nursing service.

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

21. Participates in the client’s discharge planning.

22. Maintains an on-going knowledge of current drug therapy.

23. Prepares the care plan for the paraprofessional.

JOB CONDITIONS

1. Must have a driver’s license and be willing and able to drive to client’s residences.

2. The ability to access clients’ homes which may not be routinely wheelchair accessible is required. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the client's condition and to perform and demonstrate client care.

3. Physical activities will include, walking, sitting, stooping, and standing and minimal to maximum lifting of clients and the turning of clients.

4. The ability to communicate both verbally and in writing is required as frequent communication by telephone and in writing is involved.

EQUIPMENT OPERATION

Thermometer, B/P cuff, glucometer, penlight, hand washing materials

COMPANY INFORMATION

Has access to all client medical records, personnel records and client financial accounts which may be discussed with the Director of Clinical Services

QUALIFICATIONS

1. Must be a graduate from an accredited School of Nursing.

2. Must be licensed in the State as a Registered Nurse.

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

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

5. Should be skillful in organization and in the principles of time management and have knowledge of management processes.

6. Must be able to contribute to the quality of care being rendered through constructive communication with nursing managers and staff.

7. Must have a criminal background check.

8. Must have a current CPR certification.

ACKNOWLEDGMENT

Employee Signature

Date