RN Assessment Nurse

HCR Home Care•Rochester, NY

About The Position

An RN Assessment Nurse will conduct a patient assessment in accordance with the requirements of the Home Assessment Abstract and DMS-1, and will perform these services in accordance with the physician's orders. Essential Functions Conduct initial assessment of patient and admission to the agency using a patient-centered approach. Demonstrate the coordination of the Start of Care admission process through timely, accurate communication and the establishment of trust and respect with the receiving care provider team. Adhere to the scope of practice for Registered Professional Nurse per New York State regulatory guidelines. Assume responsibility requirements and have a comprehensive understanding of various insurances. Accurately complete and submit ALL required documentation within established agency standards and guidelines. Provide and coordinate quality patient-centered care, maintaining productivity. Obtain a medical history, particularly as it related to the patient’s present condition from the patient and/or designated caregiver. Conduct a comprehensive assessment of the patient including vital signs, physical and mental status. Demonstrate critical thinking skills to be able to make clinical decisions for delivery of safe, effective, efficient, high quality patient care in collaboration with the physician. Observe and assess signs and symptoms of any adverse findings and immediately reporting to the physician including, but not limited to, reactions to ordered treatments, medication interactions, and any changes to the patients physical and/or emotional status. Demonstrate competent nursing skills, treatments, preventative procedures, knowledge, and judgment necessary to implement physician orders, nursing procedures, and nursing interventions. Develop and implement a safe, realistic, individualized Plan of Care for each patient in collaboration with other services/disciplines according to best practice standards to promote positive patient outcomes and patient satisfaction. Evaluate the patient, family, and home situation to determine specific teaching that will be required to assist the patient to reach their health goals. Initiate education for the patient and family, based on identified learning needs to home care and the delivery of professionals and paraprofessionals who will be interacting with the patient and family. Evaluate the patient’s environment to determine availability and needs for assistance from family, available support, and that a safe plan of care can be implemented in the home. Foster an environment for open communication and collaborative practice. Plan, teach, supervise, and counsel regarding physical care measures to promote health improvement, symptom management, disease complications, expected disease progression and community resources. Practice accepted nursing standards relative to infection control. Encourage a positive work environment, maintain a positive attitude, provide excellent internal/external customer service and foster teamwork by supporting and collaborating with other disciplines. Remain flexible and responsive when changes occur in workload. Communicate with patient’s Case Manager regarding established plan of care, patient’s needs and goals, and purpose of specific visit assigned. Other duties as assigned. Supervision of Home Health Aides (HHAs)/Personal Care Aides (PCAs) to include: Development of appropriate plan of care for the patient, to be followed by HHA/PCA. Evaluation of the care provided by the HHA/PCA. Documentation required in accordance with regulatory requirements including, but not limited to: Services rendered to the patient, changes noted in patient’s condition and/or family situation, and appropriate reporting of same. Progress of the patient towards established goals. Communication with other members of the health care team, including the physician. Interim medical orders obtained. Communication of the visit report to the patient’s case manager. Return demonstration of patient and/or caregiver performing specific procedures. This job description reflects management’s assignment of essential functions; and nothing in this herein restricts management’s right to assign or reassign duties and responsibilities to this job at any time.

Requirements

Graduate of an accredited school of nursing.
Current, valid Registered Nurse license issued by NYS Department of Education required.
Minimum of 1 year Home Health Care experience, specifically with OASIS-C.
Demonstrates effective teamwork.
Demonstrates effective resolution of immediate patient problems before transferring to Care Delivery Team.

Responsibilities

Conduct initial assessment of patient and admission to the agency using a patient-centered approach.
Demonstrate the coordination of the Start of Care admission process through timely, accurate communication and the establishment of trust and respect with the receiving care provider team.
Adhere to the scope of practice for Registered Professional Nurse per New York State regulatory guidelines.
Assume responsibility requirements and have a comprehensive understanding of various insurances.
Accurately complete and submit ALL required documentation within established agency standards and guidelines.
Provide and coordinate quality patient-centered care, maintaining productivity.
Obtain a medical history, particularly as it related to the patient’s present condition from the patient and/or designated caregiver.
Conduct a comprehensive assessment of the patient including vital signs, physical and mental status.
Demonstrate critical thinking skills to be able to make clinical decisions for delivery of safe, effective, efficient, high quality patient care in collaboration with the physician.
Observe and assess signs and symptoms of any adverse findings and immediately reporting to the physician including, but not limited to, reactions to ordered treatments, medication interactions, and any changes to the patients physical and/or emotional status.
Demonstrate competent nursing skills, treatments, preventative procedures, knowledge, and judgment necessary to implement physician orders, nursing procedures, and nursing interventions.
Develop and implement a safe, realistic, individualized Plan of Care for each patient in collaboration with other services/disciplines according to best practice standards to promote positive patient outcomes and patient satisfaction.
Evaluate the patient, family, and home situation to determine specific teaching that will be required to assist the patient to reach their health goals.
Initiate education for the patient and family, based on identified learning needs to home care and the delivery of professionals and paraprofessionals who will be interacting with the patient and family.
Evaluate the patient’s environment to determine availability and needs for assistance from family, available support, and that a safe plan of care can be implemented in the home.
Foster an environment for open communication and collaborative practice.
Plan, teach, supervise, and counsel regarding physical care measures to promote health improvement, symptom management, disease complications, expected disease progression and community resources.
Practice accepted nursing standards relative to infection control.
Encourage a positive work environment, maintain a positive attitude, provide excellent internal/external customer service and foster teamwork by supporting and collaborating with other disciplines.
Remain flexible and responsive when changes occur in workload.
Communicate with patient’s Case Manager regarding established plan of care, patient’s needs and goals, and purpose of specific visit assigned.
Other duties as assigned.
Development of appropriate plan of care for the patient, to be followed by HHA/PCA.
Evaluation of the care provided by the HHA/PCA.
Services rendered to the patient, changes noted in patient’s condition and/or family situation, and appropriate reporting of same.
Progress of the patient towards established goals.
Communication with other members of the health care team, including the physician.
Interim medical orders obtained.
Communication of the visit report to the patient’s case manager.
Return demonstration of patient and/or caregiver performing specific procedures.