The Registered Nurse is a qualified professional responsible for planning, coordinating, and assuring quality care services to patients and their families in a home health setting. The nurse provides professional nursing services in clients’ homes and case-manages primary patients, monitoring changing patient and family needs, conducting initial assessments, overseeing progress toward goals, and monitoring clinical outcomes. In collaboration with patients or their representatives, the nurse develops, implements, and continuously monitors plans of care. The role includes maintaining communication with patients, families, physicians, other disciplines, the Clinical Manager, and office staff; participating in interdisciplinary conferences; completing clinical documentation such as OASIS, evaluations, orders, and care coordination records; and working with physicians and discharge planners to promote patient and caregiver health education. The nurse also serves as a liaison to community health resources, including DME, oxygen, and infusion services, and pursues ongoing professional development.
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