This role is responsible for direct patient care for assigned patients. The Registered Nurse evaluates the clinical needs of the patient, initiates, develops, implements, and makes necessary revisions to the patient's plan of care, addressing all problems in the plan of care and documenting accordingly. The nurse will utilize clinical grouping guidelines, including those for appropriate interdisciplinary utilization, to capture and data enter the initial visit frequency. They will ensure OASIS assessment accurately reflects documentation and vice-versa. The role involves updating the Clinical Manager regarding referrals to community resources, participating in inter-disciplinary patient case conferences, and assisting in evaluating the effectiveness of the established plan of care. Additionally, the nurse will instruct and provide documented supervision of the Home Health Aide plan of care every 14 days, notify the MD/other involved care providers and Clinical Team Manager of significant changes in the patient’s condition, and complete admission and other paperwork on a timely basis. The nurse will record narrative documentation to reflect skilled care, ensuring it is clear, concise, complete, and captures and addresses the specifics of teaching, direct care, and patient/caregiver response. Obtaining and clarifying valid MD orders for all care delivered is essential. In collaboration with the Clinical Manager and interdisciplinary team, the nurse will plan and coordinate discharges appropriately, inform the patient/MD, and record the disposition of the patient in the discharge summary, completing all appropriate discharge paperwork. Other duties as assigned.
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Job Type
Full-time
Career Level
Mid Level