- Responsible for direct patient care for assigned patients
- Evaluates the clinical needs of the patient; initiates, develops, implements and makes necessary revisions to the patient's plan of care; addresses all problems in the plan of care and documents accordingly.
- Utilizes clinical grouping guidelines including guidelines for appropriate interdisciplinary utilization to capture and data enter the initial visit frequency
- Ensures OASIS assessment accurately reflects documentation and vice-versa.
- Updates the Clinical Manager regarding referrals to community resources as appropriate.
- Participates in inter-disciplinary patient case conferences; assists in evaluating effectiveness of established plan of care.
- Instructs and provides documented supervision of the Home Health Aide plan of care every 14 days.
- Notifies MD/other involved care providers and Clinical Team Manager of significant changes in the patient's condition.
- Completes admission and other paperwork on a timely basis.
- Records narrative documentation to reflect skilled care. Documentation is clear, concise, complete and captures and addresses the specifics of teaching, direct care and response of patient / caregiver.
- Obtains and clarifies valid MD orders for all care delivered.
- In collaboration with Clinical manager and interdisciplinary team, plans and coordinates discharges appropriately and informs patient/MD and records disposition of patient in the discharge summary. Completes all appropriate discharge paperwork.
- All other duties as assigned.
Sign-On Bonus Eligible!
- Current RN license in Mass. and other related credentials to meet specialty.
- Minimum one (1) year of nursing experience required or 6 months of nursing experience with a BSN.
- CPR certification required.
- Home care and IV experience, computer skills and BSN preferred.