ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES:

Patient Care:

• Completes an initial, comprehensive and ongoing assessments of patient and family to determine home health needs. Provides a complete physical assessment and history of current and previous illness(es).
• Provides professional nursing care by utilizing all elements of nursing process.
• Assesses and evaluates patient’s status by:
• Writing and initiating plan of care
• Regularly re-evaluating patient and family/caregiver needs
• Participating in revising the plan of care as necessary
• Uses health assessment data to determine nursing diagnosis.
• Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative 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 in the physician’s plan of care.
• Counsels the patient and family in meeting nursing and related needs.

Communication:

• Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given. Records pain/symptom management changes/outcomes as appropriate.
• Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
• Communicates with community health related persons to coordinate the care plan.
• Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group.
• Provides and maintains a safe environment for the patient.
• Assists the patient and family/caregiver and other team members in providing continuity of care.
• Works in cooperation with the family/caregiver and home health Interdisciplinary Group Members to meet the emotional needs of the patient and family/caregiver.
• Attends interdisciplinary group meetings.