Develops a written plan of care for each patient based upon indications obtained by including completing a comprehensive OASIS Assessment on all clients who meet OASIS requirement regulations.
Provides skilled nursing care as ordered by prescribing physician.
Assesses patient's condition, initiates plan of care, re-evaluates and updates as necessary.
Ability to adequately assess and reassess pain utilizing a formal standardized pain assessment tool. Utilizes appropriate pain management techniques. Educates the patient and family regarding pain management.
Performs all aspects of patient care in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
Obtains all necessary physician orders and collaborates with the physician as the patient's needs dictate.
Participates in case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc.
In coordination with scheduler and other disciplines involved in the delivery of care, plans patient discharge from the agency. Recommends referrals for alternative level of care if necessary.
Recommends to physician needed referrals to other disciplines and/or community resources.
Obtains needed supplies and equipment to provide care.
Performs patient care responsibilities considering needs specific to the standard of care for patient's age, pediatric through geriatric.
Plans with the physician to implement changes to improve patient care.
Reports changes in patient's physical and emotional health to the physician.
Communicates patient's data and observations verbally and through documentation.
All documentation, charting and agency forms are completed in the designated time.
Demonstrates knowledge of medications and their correct administration based on age of patient and patient's clinical status.
Addresses and supports cultural practices as long as these practices do not harm the patient/family or interfere with the planned course of medical treatment.
Adheres to all agency, billing and documentation policies and procedures.
The registered nurse will see 4.5 to 5 clients per day as a measure of productivity.
Start of care/Resumption of care assessments counts as 1.5 visits
All other OASIS assessments count as 1 visit (presuming a visit is completed) 1) Discharge OASIS; 2) Recertification other follow up; 3)Transfer; 4) Death at home
Daily visits count as 1 visit
The registered nurse will be responsible for all components of the home health paperwork. This paperwork will need to be completed in a timely manner. Daily notes are to be handed in daily. OASIS assessments need to be completed and handed in within 48 hours. The paperwork will need to be accurate and reflect the treatment modalities, and the client's response to the prescribed treatment. Accurate paperwork will be described as five percent or less error margin. Paperwork includes but may not be limited to; 1) OASIS assessments 2) Daily notes 3) Sixty day summaries; 4) Case conference documentation; 5)Interim orders; 6)Discharge summaries 7) Medication profiles 8) Nursing narrative notes
Teaches, supervises and counsels the patient and family members regarding nursing care needs.
Follows up with obtaining lab results and notifies the physician of any significant changes.
Adheres to dress code.
Completes annual educational requirements.
Maintains regulatory requirements.
Wears identification while on duty.
Maintains confidentiality at all times.
Attends department staff meetings as required within the department.
Reports to work on time and as scheduled; completes work in designated time.
Represents the organization in a positive and professional manner.
Actively participates in performance improvement and continuous quality improvement (CQI) activities.
Coordinates efforts in meeting regulatory compliance, federal, state and local regulations and standards
Communicates and complies with the Benefis Health System Mission, Vision and Values as well as the focus statement of the department.
Complies with Benefis Health System Organization Policies and Procedures.
Complies with Health and Safety Standards and Guidelines.