As primary individual accountable for coordinating the patient-centered care for the healthcare team, is responsible for providing all services in accordance with the Nurse Practice Act, federal, state, and local laws, and within the guidelines of his/her professional organization. Completes an initial, comprehensive, and ongoing assessment of patient and family to determine hospice needs. Provides a complete physical assessment and history of current and previous illness(es). Provides professional nursing care by utilizing all elements of the nursing process. Assesses and evaluates patient's status by writing and initiating plan of care, regularly re-evaluating patient and family/caregiver needs, and participating in revising the plan of care as necessary. Responsible for the planning, coordinating, and delivery of quality interdisciplinary home health care services. Compliance with company standards and federal/state guidelines will be maintained at all times. Initiates the plan of care and makes necessary revisions as patient status and needs change. Uses health assessment data to determine nursing diagnosis. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process. Initiates appropriate preventive and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician in the physician's plan of care. Counsels the patient and family in meeting nursing and related needs. Provides health care instructions to the patient as appropriate per assessment and plan. Assists the patient with the activities of daily living and facilitates the patient's efforts toward self-sufficiency and optional comfort care. Acts as Case Manager when assigned by Clinical Director/Director of Professional Services or the Clinical Supervisor/Assistant Director of Professional Services and assumes responsibility to coordinate patient care for assigned caseload. Completes maintains, and submits accurate and relevant clinical notes regarding the patient's condition and care given. Records pain/symptom management changes and outcomes as appropriate. Communicates with the physician regarding the patient's needs and reports changes in the patient's condition; obtains/receives physicians' orders as required. Communicates with community health related persons to coordinate the care plan. Teaches the patient and family/caregiver self-care techniques as appropriate. Provides medication, diet, and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers. Works in concert with the interdisciplinary group. Attends IDG, submit orders, on-call |