The Skilled Nurse has clinical nursing knowledge, physical assessment, teaching and procedural skills.
He/she has the ability to be directly responsible for assessing, planning, providing and documenting
nursing care for a designated group of patients in accordance with the physician?s plan of care and
Truecare Nursing Services policies and procedures. The provisions of quality care is accomplished by implementing, supervising and coordinating services provided and completes documentation affectivity and timely.
DUTIES AND RESPONSIBILITIES
1. Completes referrals and takes physician?s verbal orders as necessary in a timely manner.
2. performs physical assessment, evaluates patient?s needs and consults with physicians if necessary to develop plan of care and documentations and in timely manner.
3. Assesses need for additional health or ancillary services and prefers patients for service(s) when appropriate, on a timely basis.
4. Assesses family and home environment and makes recommendations, which will enhance patient care and promote safety.
5. Involves patients and/or family in developing and revising an individualized care plan including necessary teachings with realistic goals, update plane of care as goals are met or change in
intervention as required and documents changes appropriately.
6. Coordinates the multidisciplinary care team and plans for patient care and documents appropriately.
7. Interprets the admission, discharge and other policies of the company, physician, family, other health care providers as needed.
8. Provides clear, written and verbal Home Health Aide and LPN assignments, updates instructions
9. Provides skilled nursing care and assessments to patients according to the plan care and promptly revises the plan, as necessary, in consultation with the physician and other team member. Establishes and modifies goals as appropriate.
10. Informs and provide progress notes to the patient?s physician and podiatrist about patients under care. When the patient?s conditions changes or there are deviations from the plan of care
and submit in writing patient?s summary of care.
11. Initiate appropriate preventive, rehabilitative, comfort, pain management nursing procedures and provides instructions to patients and staff in a timely manner. Follows companypolicies and utilizes company forms in documenting forms.
12. Explains to the patient and family the diagnosis and the nature of the treatment consistent with physician?s orders and plan of treatment.
13. Performs specialized care in accordance with the competencies and demonstrates initiative in learning new skills and developing competency.
14. Completes clear, concise and accurate clinical notes which documents skilled services and other required documentation appropriately and timely.
15. Communicates necessary information to the Director of Nursing.
16. Demonstrates professionalism by maintaining high standards of clinical care and staying current on clinical and medical issues.
17. Work with patient, family and health care team members effectively to coordinate services and to promote quality care and possible patient care outcomes.
18. Establishes and maintains working relationship and open lines of communication with personnel from physician?s offices, area hospitals, clinics, etc. to assure flow on information.
19. Completes nutritional assessments and provides patient/caregiver instructions on diet/nutrition and seeks consultation as necessary.
20. Uses appropriate teaching material and techniques to obtain position outcomes and seek consultation as necessary and documents patient/caregiver outcomes on company forms.
21. Uses appropriate infection control procedures and safety measure.
22. Administrators CPR, provides emergency care necessary and maintains current CPR certifications.
23. Assists in orienting/precepting new staff when necessary.
24. Provides and documents services in accordance with State, Federal, Medicare, Medicaid regulations as applicable.
25. Performs job duties and uses resources appropriately.
26. Coordinate with Administrator/DON program to improve deficient services and the development and implementation of plan of correction
27. Adheres to policies and procedures of Truecare Nursing Services.
28. Performs other duties as assigned by the Director of Nursing.