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REGISTERED NURSE JOB DESCRIPTION
DEFINITION:
The Registered Nurse, under direction of the Case Manager or Director of Clinical Services, provides skilled nursing services to a private duty patient. This includes direct and indirect care. Responsibilities include planning, giving and evaluating nursing care. The functions performed require judgment based upon established policies of the institution.
LINE OF AUTHORITY:
· Reports directly to the Case Manager (Medicare) or Director of Clinical Services (Private).
· Oversees services provided by the Licensed Practical Nurses, Home Health Aides and Companion Sitters
· Accountable to the nurse in charge of the patient (DCS/RN SUPERVISOR).
· Works closely with patient, visitors, hospital staff and volunteer workers.
QUALIFICATIONS:
Education
- Graduate of a State accredited nursing program and licensed to practice as a Registered Nurse in the State of Florida or possess an endorsement from the Florida State Board of Nursing while awaiting nursing license.
- Maintains current CEU’s.
Experience
- Must have at least one year of experience in an acute care setting.
Health
- Evidence of good health as stated by a physician.
- Negative PPD or Chest X-Ray.
- Physically able to perform duties without limitations.
- Mentally and emotionally able to perform duties.
Abilities
- Must have physical abilities to adequately perform described duties.
- Ability to identify problems, learn and apply professional training, follow physician’s orders, produce accurate records of activities and services provided, and plan a reasonable course of action in an organized manner consistent with standard nursing practices.
- Able to see and hear adequately to respond to auditory and visual requests which relate to the coordination of Agency activities.
- Able to speak in a clear, concise voice in order to communicate direction for Agency activities and staff.
- Demonstrates positive interpersonal communication skills with the ability to effectively communicate with patients, physicians and staff.
- Demonstrates adequate mental acuity to perform duties stated under Responsibilities and Duties.
- Ability to organize work procedures, assume responsibility and effectively supervise others.
- Demonstrates exceptional assessment skills.
- Demonstrates adequate knowledge regarding exposure to body fluids, and chemicals, and some hazardous equipment.
RESPONSIBILITIES AND DUTIES:
· Provides case management as described in 59A8.002 (5), F.A.C. for all cases involving nursing and therapy services.
· Conducts the admission of the patient to the Agency by:
- Obtaining a medical history, particularly as it relates to the present condition.
- Conducting physical examination of patient.
- Makes the initial evaluation visit and evaluates the patient, significant other(s) and home situation to determine what health teaching will be required, what assistance will be available from the family in caring for the patient and what community services will be required.
- Interpreting nursing and other services of the Agency to patients and families as a part of planning for care.
- Assuring appropriateness of physician’s orders and discussing necessary changes.
- Assists in the development and implementation of the interdisciplinary patient care plan as it pertains to nursing, evaluates the effectiveness of nursing intervention on a regular basis and updates the patient care plan as needed, and provides skilled nursing care as outlined in the patient care plan to include the following:
- Nursing services, treatments, diagnostic and preventive procedures requiring substantial and specialized nursing skill as appropriate for the patient’s care and safety.
- Initiating preventive and rehabilitative nursing procedures as appropriate for the patient’s care and safety.
- Observing signs and symptoms and reporting to the physician reactions to treatments, including drugs, and changes in the patient’s physical or emotional condition.
- Teaching, supervising and counseling the patient and family members regarding the nursing needs and other related problems of the patient at home.
- Communicates with the physician at least every sixty (60) days regarding the patient’s status, obtaining additional orders if necessary.
- Maintains and submits written progress notes, clinical and agency records as deemed necessary to include:
- Care plan
- Daily notes
- Weekly schedules
- Discharge summary
- Discusses and plans with the Case Manager or Director of Clinical Services, at least weekly, the following:
- Next week’s schedule including necessary frequency of visits.
- Patient’s general condition and required care and necessary changes on the Plan of Treatment.
- Communicates with other team members in order to provide comprehensive patient care.
- Coordinates services.
- Assumes responsibility for self-development by continually striving to improve his/her nursing knowledge through educational programs, attendance at workshops and conferences, active participation in professional and related organization meetings and individual research and reading and In-Service programs to train and teach other nursing personnel.
- Assumes responsibility for each patient receiving nursing or personal care.
- Provides supervision for the care given by the Home Health Aide to assigned patients and does the following:
- Supervises and evaluates the care given by the Home Health Aide every fourteen (14) days and more frequently if necessary.
- Provides written instructions for care.
- Participates in periodic conferences with the Case Manager or Director of Clinical Services concerning the Home Health Aide’s performance.
- May assign selected portions of patient care to Licensed Practical Nurses and Home Health Aides but always retains full responsibility for the care given for supervisory visits to the patient’s home
- Maintains confidentiality of patient and agency matters.
Regulatory Reference: Federal Conditions of Participation Tag G171, G172, G173, G174, G175, G176, G177, G178, G223, G224
Regulatory Reference: Florida AHCA Tag H230, H231, H240, H248
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