The Registered Nurse provides professional nursing services in patients’ homes and is responsible for planning, coordinating, and ensuring quality care for patients and their families. The role includes case management for primary patients, assessing changing patient and family needs, and monitoring progress toward care goals and clinical outcomes. In collaboration with patients or their representatives, the nurse develops, implements, and monitors plans of care. The nurse communicates with patients, families, physicians, other disciplines, the Clinical Manager, and office staff; participates in interdisciplinary conferences; and completes clinical documentation, including OASIS, evaluations, orders, and care coordination records. The role also involves working with physicians and discharge planners, providing health education to patients or caregivers, and connecting patients with community health resources such as DME, oxygen, and infusion services. The nurse is expected to pursue ongoing education and professional development.
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