Admissions Registered Nurse Home Care

Job Description Summary

An interdisciplinary team member who primarily completes Admissions (Starts of Care, Resumptions of Care, 2nd Service Evaluations). The Admission Nurse will also complete routine visits as indicated. Position requires a minimum of 2 years of prior home care experience, proficiency in OASIS Assessments and documentation, comfort managing a variety of clinical and psychosocial needs, organizational and communication skills, and flexibility. Previous experience with EPIC preferred.

Job Description

ESSENTIAL FUNCTIONS

Under the direction of the Clinical Manager, evaluates, plans and administers medically prescribed nursing treatment to patients in their home.

1. INITIAL PATIENT ASSESSMENT:
Performs a comprehensive physical, psycho-social, and safety assessment of assigned patients as evidenced by clinical documentation. Identifies medical concerns and establishes interventions and goals to achieve measurable outcomes.

2. INITIAL ASSESSMENT DOCUMENTATION:
Completes thorough documentation of Admissions, Resumptions of Care, and Second Service Evaluations. A Plan of Care is established identifying realistic and measurable goals. Consistently completes all paperwork required to provide service to patient. Med reconciliation is completed for Agency Admissions, Resumptions of Care, Second Service Evaluations, and with every new medication entered into medical record. Synchronization of all documentation is timely and according to Agency guidelines.

3. REVISITS: TREATMENTS AND DOCUMENTATION:
Plans for and provides skilled nursing treatment in the home reassessing patient status on each visit and ensuring quality of care as documented in the clinical record. Treatment plans are modified appropriately to reflect change in patient status and progression towards goals. Pain and vital signs are assessed and documented on every visit.

4. COORDINATION OF PATIENT CARE:
Coordinates patient care with other clinical team members ensuring optimal patient care. Communications are documented in the clinical record. MD is notified of any changes in patient status and also when visit frequency is not met per MD order.

5. RECERTIFICATIONS:
Agency Recertifications are completed within the 5 days prior to the end of Certification period with thorough completion of OASIS. Recertifications are completed with accurate updated orders documented in the chart. Interdisciplinary communication regarding recertification occurs prior to recertifying patient.

6. DISCHARGES:
Discharge planning occurs throughout the episode of care with documentation reflecting that the pt has been prepared for discharge. Discharge is communicated to all disciplines involved and MD is notified of discharge as reflected in the medical record. Discharge summaries are completed and goals and interventions are ended. All required paperwork is appropriately signed by patient/Health Care Proxy indicating notification of discharge.

7. TECHNOLOGY:
Demonstrates proficiency and competency in the agency/program automated clinical record as evidenced by successful completion of education program and appropriate daily utilization of software.

8. SAFETY:
Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. Demonstrates proper Infection Control during joint visits.

9. SCHEDULING:
Maintains up to date schedule in computerized system, identifying availability for new patients. Keeps patients informed as to their individualized schedules.

10. PROFESSIONAL DEVELOPMENT:
Maintains and enhances individual knowledge as well as promoting professional standards in nursing. Maintains current knowledge in nursing practice by attendance in-services. Participates on Committees or Team projects as able.

MINIMUM EDUCATION :
Bachelor of Science in Nursing

REQUIRED LICENSES :
Massachusetts Registered Nurse License