RESPONSIBILITIES

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

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

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

Prepare and present 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.

Coordinate patient services.

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

Submit a tally of patient care visits made each day.

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

Discuss 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.

Obtain orders for paraprofessional service and submits a referral to the appropriate personnel. Participate in the patient's discharge planning process.

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

Participate 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.

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

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

Participate in the patient's discharge planning process.
Maintain an on-going knowledge of current drug therapy.
Adhere to Federal, state and accreditation requirements including Medicare and Medicaid regulations. May be requested by Clinical to fill in for the other nurses.