Under the general supervision of the Home Health Clinical Manager, provides professional nursing services to individuals in their home through a process of nursing assessment, planning, care and evaluation in accordance with physicians’ orders, the established plan of care, the patient’s diagnosis, corporate policy and procedures and the Nurse Practice Act. Carries primary case management functions for assigned patients.
Performs initial assessment visit to develop Plan of Care that includes realistic and measurable age-appropriate patient goals in collaboration with the patient, family, and members of the health care team. Additional responsibilities include, but not limited to:
- Performs a complete health assessment.
- Implements and evaluates the interventions identified in the Plan of Care and updates and revises, as necessary.
- Assesses the physical, psychosocial, spiritual, and environmental needs of the patient and family and develops goals and Plans of Care.
- Reassesses health care needs on each subsequent visit and modifies the Plan of Care with any change in patient condition.
- Advocates for clients in obtaining needed services.
- Discharges the patient, when appropriate, notifying the physician and manager. Instructs the patient and/or family how to access any necessary follow-up.
- Develops a written Plan of Care in accordance with the patient’s diagnosis and family needs, physician orders, and the Corporation’s policies and procedures. Coordinates the development of the Plan of Care with other disciplines providing care for the patient.
- Observes, evaluates, and reports to physician any changes that would suggest a need to alter the Plan of Care.
- Graduation from a State accredited Nursing Program and valid license to practice in the State of Pennsylvania.
- Ability to cope with occupational hazards such as exposure to contagious diseases, extreme weather conditions, domestic pets and dilapidated residences.
- Experience utilizing a laptop and/or personal computer, preferred.