POSITION
DESCRIPTION
POSITION TITLE: Registered Nurse / Community Services JOB CODE: 585
THIS POSITION
REPORTS TO: Coordinator, Patient Care
SERVICE
AREA: Community Services
POSITION
PURPOSE: The Registered Nurse provides
nursing care for clients during a
specified episode of care, including 24-hour and
weekend needs. The nurse functions in a
structured care setting, described as geographic
and/or situational environments where the
policies and procedures for provision of health care
are established. This nurse receives
assistance from the Nurse Manager (NM) and other
resources.
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PRINCIPLE ACCOUNTABILITIES AND
ESSENTIAL DUTIES OF THE JOB:
* The Registered Nurse manages care of
clients from admission to discharge in Home
Health/Hospice utilizing
critical pathways.
-
Collects data from available resources, using established assessment
format, to
identify
ongoing nursing/other discipline care needs and makes care/service
decisions
based on that assessment.
-
Organizes and analyzes data to establish nursing care plans.
-
Utilizes negotiation with the client to establish short-term goals that
are
consistent
with the overall plan of care.
-
Implements an individualized plan of care using established nursing
diagnoses,
structure
and process standards, and critical pathways.
-
Evaluates client responses and modifies nursing interventions as
necessary to
meet client
needs.
-
Modifies the planned care based on reassessment, changes in therapeutic
and
diagnostic
orders, the patient's need for further care or services, and the
achievement
of identified goals.
-
Applies interpreted nursing research findings for nursing care.
-
Identifies actual problems, lack of resolution to problems, and
initiates
appropriate
action.
-
Collaborates with NM regarding patients not reaching potential or
patients in
crises.
* The Registered Nurse participates in
interactive communication.
-
Assesses the client to determine immediate emotional needs and learning
readiness
with pre-established POC and initial home visit. Facilitates patient
interaction
in POC development.
-
Implements goal-directed interactions.
-
Improves patient health outcomes by promoting recovery, facilitating
patient
comfort,
hastening return to function, promoting health behavior, and
appropriately
involving the patient in his or her care or service decisions.
-
Modifies and evaluates a standard teaching plan to restore, maintain or
promote
health.
-
Networks with health care team members by communicating data based on
critical
pathways to
provide continuity of care. Maintains
coordination role for the
patient with all
disciplines.
-
Collaborates with other health care team members in interdepartmental
issues/recognition/resolution
by case conference.
-
Facilitates long-term coping mechanisms and lifestyle changes.
-
Maintains confidentiality of information regarding clients, families,
health
care
personnel and the
* The nurse provides direct nursing care for
the client for a specified time.
-
Provides nursing care for the client while identifying and communicating
with
the primary
care givers or significant others.
-
Assesses and prioritizes the delivery of direct nursing using time and
resources
effectively
and efficiently.
-
Performs nursing tasks/skills, both legally and safely.
-
Monitors and reports immediate patient responses to nursing/medical
treatments
and documents
variances from critical pathways.
-
Delegates and refers aspects of care to the care team members consistent
with
their roles
and responsibilities.
-
Assumes responsibility and accountability for the direct nursing care
provided
and the
management of the care.
-
Reports changes in patient condition, progress, or lack of progress, to
the
appropriate
physician.
* Defines and shapes processes and activities
to maximize coordination of care and
services.
-
Care and services flow continuously from assessment through planning,
care and
reassessment.
-
The client's care and services are coordinated among staff members and
other
disciplines
through delegation and scheduling.
Provides clinical follow-up to
insurance
case managers.
-
The client's status and the need for continuing care and services are
assessed.
-
For hospice care, the family is assessed to determine ongoing
bereavement and
spiritual
needs. Continuous evaluation is made of
their ability to handle
stress.
-
Referrals are made to settings and organizations to meet continuing
needs, as
appropriate.
-
Recognizes and responds to emergencies.
-
Takes steps in planning and implementing appropriate discharge planning.
-
From initial assessment facilitates patient and care givers self care
ability.
Recognizes
priorities in patient care.
Follows policy and procedure in
completing
documentation in a timely manner.
-
Documentation reflects standard medical terminology, accepted
abbreviation,
individualized
patient assessment, and nursing intervention.