Home Health RN

Patient Care

• Completes an initial assessment of patient and family to determine home care needs.
• Provides a complete physical assessment and history of current and previous illness(es).
• Regularly re-evaluates patient nursing needs.
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.
• Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Administers medications and treatments as prescribed by the physician.
• Provides direct patient care as defined in the State Nurse Practice Act.
• Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan of care.
• Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
• Acts as Case Manager when assigned by Clinical Manager and assumes responsibility to coordinate patient care for assigned caseload.

Communication

• Prepares clinical notes and updates the primary physician when necessary and at least every 60 days.
• Communicates with the physician regarding the patients needs and reports any changes in the patients condition; obtains/receives physicians orders as required.
• Communicates with community health related persons to coordinate the care plan.