- Develops care plans based on patient nee
- Establishes priorities for the delivery of care to formulate effective care plans/clinical guidelines.
- Interview patients and families on the initial visit and together with them and the M.D. develops the home care treatment plan.
- Evaluates patients’ and families’ educational needs, and develops and implements appropriate teaching programs.
- Understands and incorporates resources and functions of other health-care professionals in the delivery of comprehensive care plans.
- Assesses for changes in the patients’ condition on an ongoing basis and reflects those changes in the medical record by updating care plans, medication records and the like.
- Renders professional nursing care by performing both complex and routine treatments as prescribed by physicians or in accordance with their care plans or condition.
- Coordinates Patient Services
- Performs active chart review to ensure completeness of the medical record on an ongoing basis.
- Documents telephone calls to physician when there is a change in patient condition or as per agency policy.
- Documents case conferences with involved disciplines every two weeks.
- Supervises and directs supporting Home Health Aide personnel in treatment of patients by providing plan of care and incidental teaching for effective implementation of the care plan minimally every two weeks.
- Performs related activities, i.e., communicating with Hospital departmental personnel to resolve operational problems and to obtain supplies.
- May be assigned duties as a coordinator to meet the needs of the department.
- Assumes ongoing primary nursing and coordination responsibilities for an assigned caseload of patients.
- On an ongoing basis reviews all documentation placed into the medical record or entered into the computerized record. This includes but is not limited to aide service reports, social work notes, therapy notes, laboratory reports, billing information etc.
- Understands and utilizes information regarding the home care payment system to ensure correct reimbursement from payors on every medical record.
- Ensures by review the completeness of the medical record at the time of discharge.
- Reports off to the supervisor with the status of the caseload and any intervention necessary prior to extended days off or vacation.
- Completes all necessary paperwork at the end of the shift.
- Communicates the notebook as per policy to ensure the exchange of patient information
- Forwards all pertinent patient information as it is received to the managed care coordinator to facilitate reimbursement.
Scheduling of Patient Visits
- Schedules all revisits as per the plan of care.
- As per the agency needs, accepts new cases.
- Communicates potential scheduling difficulties to the supervisor/scheduling coordinator.
- On the previous day, provides the supervisor/scheduling coordinator with an accurate number of visits for the next day.
- Accepts on-call responsibility as assigned.
- As assigned performs weekend and holiday rotation.
Participates in research programs and studies. Implements performance activities and participates in related committees.
Assists in orienting and training new personnel, and serves as a resource for other personnel in resolving patient care problems.
Maintains knowledge of current trends and developments in the field by reading appropriate books, journals and other literature and attending related conferences, seminars and the like.
Accepts assignments based on demonstrated competency to provide care to age and gender specific population.
Attends monthly staff meetings.
Attends scheduled team meetings.
Participates on departmental committees
Exhibits a working knowledge of the department’s performance improvement functions by completing required logs, understanding and gathering data for studies and the like.
Complies with Department of Health regulations regarding care to patients’ and documentation of it as to not put the agency into a deficiency mode.