The Registered Nurse is a qualified professional responsible for planning, coordinating, and assuring quality care services to patients and their families. The nurse develops work methods and procedures that facilitate high-quality care, delivers professional nursing services in clients’ homes, and provides case management for primary patients. The role monitors changing client and family needs, conducts initial assessments, oversees progress toward goals, and monitors clinical outcomes. The nurse maintains ongoing communication with patients, families, physicians, other disciplines, the Clinical Manager, and office staff, and participates in interdisciplinary staff conferences. In collaboration with patients or their representatives, the nurse develops, implements, and continuously monitors the plan of care. Responsibilities also include clinical documentation, including OASIS, evaluations, orders, and care coordination documentation; working with physicians and discharge planners; promoting health education for patients and caregivers; and liaising with community health resources such as DME, oxygen, and infusion providers. The nurse interacts with patients, families, team members, and other healthcare professionals and participates in ongoing education and professional development.
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