RN Primary MNA, Martha's Vineyard, VNA of Cape Cod

Cape Cod Healthcare•Vineyard Haven, MA

About The Position

The RN Primary is responsible for direct patient care for assigned patients. The nurse evaluates clinical needs; initiates, develops, implements, and revises patient plans of care; addresses problems in the plan; and documents care. The role uses clinical grouping guidelines, including interdisciplinary utilization guidelines, to determine and enter initial visit frequency, and ensures the OASIS assessment accurately reflects the documentation and vice versa. The RN Primary participates in interdisciplinary patient case conferences and helps evaluate the effectiveness of care plans. The nurse instructs and documents supervision of the Home Health Aide plan of care every 14 days, communicates significant changes in patient condition to the physician, other involved care providers, and Clinical Team Manager, and completes admission and other paperwork in a timely manner. The role requires clear, concise, complete narrative documentation of skilled care, including teaching, direct care, and patient or caregiver response. The nurse obtains and clarifies valid physician orders for all care delivered. In collaboration with the Clinical Manager and interdisciplinary team, the RN plans and coordinates discharges, informs the patient and physician, records the patient's disposition in the discharge summary, and completes the required discharge paperwork. Other duties may be assigned.

Requirements

Current RN license in Massachusetts and other related credentials to meet the specialty.
At least one year of nursing experience, or six months of nursing experience with a BSN.
CPR certification.
Successful passage of the VNA pre-hire medication test.

Nice To Haves

Home care experience.
IV experience.
Computer skills.
BSN.

Responsibilities

Provide direct patient care to assigned patients.
Evaluate patients’ clinical needs and initiate, develop, implement, and revise plans of care as necessary.
Address all problems in the plan of care and document accordingly.
Use clinical grouping guidelines, including guidelines for appropriate interdisciplinary utilization, to capture and enter initial visit frequency.
Ensure the OASIS assessment accurately reflects documentation and vice versa.
Update the Clinical Manager regarding referrals to community resources as appropriate.
Participate in interdisciplinary patient case conferences and assist in evaluating the effectiveness of established plans of care.
Instruct and provide documented supervision of the Home Health Aide plan of care every 14 days.
Notify the physician, other involved care providers, and Clinical Team Manager of significant changes in the patient’s condition.
Complete admission and other paperwork in a timely manner.
Record clear, concise, complete narrative documentation that reflects skilled care, including teaching, direct care, and the patient’s or caregiver’s response.
Obtain and clarify valid physician orders for all care delivered.
Plan and coordinate discharges with the Clinical Manager and interdisciplinary team; inform the patient and physician, document patient disposition in the discharge summary, and complete discharge paperwork.
Perform other duties as assigned.