DUTIES AND RESPONSIBILITIES:
1. Conduct assessments in order to admit patients to the agency’s services
A. Obtains a medical history.
B. Provides a complete physical assessment of the patient at start of care and
during each assigned shift/visit to establish a baseline, identify problems and
determine changes in condition requiring follow-up and develop interventions
C. Evaluates family in care provision to determine competency, education needed
and what assistance will be available from family members in providing care.
D. Interprets nursing and other services of the agency to clients and families as a
part of planning for care.
2. Continually updates the nursing care plan as needed.
3. Adhere to the established care plan and the physician’s plan of treatment
4. Provide skilled nursing care as outlined in the nursing care plan to include the following:
A. Nursing services, treatments and procedures requiring substantial specialized
skill as ordered by the physician.
B. Initiating rehabilitative nursing services as appropriate for the patient’s care and
C. Assesses signs and symptoms, and patients response to treatment; reports
changes to the physician requiring changes to the plan of care.
5. The Registered Nurse documents assessments, services provided, including changes noted
in the patient’s condition, family dynamics and support systems, revises the care plan as
needed, evaluates care provided and progress toward goals.
6. Maintain the confidentiality of the patient’s condition and clinical record.
7. Demonstrate sound clinical judgment
8. Maintain professional boundaries with patients and their families
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9. Represents the professional interests of the company to patients, clients and their family
10. Report changes in the patient’s condition to the physician and clinical manager
11. Maintain professional demeanor at all times
12. Refer questions or concerns patient and/or family member may have regarding Agency
policies and procedures or scheduling to appropriate Agency personnel
13. Discuss scheduling issues with staffing coordinators. Does not discuss scheduling issues
directly with patient’s or their families
14. Report incidents, accidents or injuries of either employee or patient to clinical manager or
branch director promptly
15. Evaluate the effectiveness of the nursing service
16. Consult with the clinical manager concerning alterations in the plan of treatment.
17. Prepare and submits all required paperwork at least weekly
18. Submit summary of services as directed by the clinical manager; discusses issues,
problems and concerns relating to patient care or services with the clinical manager
19. Ensure care is coordinated among all clinical staff, and external providers (e.g., DME
company, respiratory company, etc)
20. Cooperate with other agencies providing nursing or related services to provide continuity
of care and to implement a comprehensive care plan.
21. Is responsible for the care and safekeeping of agency property.
22. Participate in staff meetings as directed
23. Participate in the planning, operation and evaluation of the nursing service.
24. Continually strives to improve nursing care by broadening knowledge through formal
education, attendance at workshops, conferences, active participation in professional and
related organizations and individual research and reading
25. Follow company policies and procedures.
26. Maintain licensure in the state(s) of practice.
27. Maintain confidentiality regarding all aspects of patients and/or employee information in
compliance with HIPAA rules. Maintain compliance with applicable state and federal
regulations, company policies/procedures and accreditation standards.
III. OTHER QUALIFICATIONS:
A. Compliance with all requirements set forth in company policy, state/federal regulation and
within the company’s compliance program
B. The ability to comprehend and follow directions and instructions as appropriate given by
the company, supervisory personnel and in compliance with physicians orders. Acts as an
advocate for the patient.
C. Maintain appropriate documentation of services provided in order to meet regulatory
requirements, company policy and to ensure reimbursement for services provided