A Home Health nurse is a Professional Registered Nurse who provides quality nursing care to patient in accordance with recognized nursing techniques, procedures, standards, policies of Penn Highlands Clearfield and Home Health Department as well as complies with established principles of Medicare OASIS assessment tool. Responsible for the provision of direct and indirect patient care, using sound, prudent and often independent judgment. Responsible for planning, directing, performing patient care in close coordination with other disciplines, agencies, physicians and caregivers. Presents self in an open, friendly and professional manner.
*Complies with PENN HIGHLANDS CLEARFIELD policies and procedures, accreditation agency requirements, and federal, state or local law and regulations
1. Critical Thinking
a. Obtains information in a systematic, unbiased fashion.
b. Able to decern meaningful information.
c. Able to apply information in a meaningful way to prioritize care, problem solve and in decision making.
d. Capable of identifying real and potential problems and issues
a. Schedules patient visits according to patient need and to meet patient goals.
b. Maintains own master schedule for patient visits to avoid and prevent missed visits, labs, re-certifications or treatments. Inclusive of obtaining authorizations for patient visits.
c. Receives and intervenes appropriately and timely with lab results, physician orders.
d. Takes responsibility to inform others of patient needs, conditions or plan when someone else must see patient.
e. Participates in OBQI measures.
f. Participates in self-evaluation using patient outcomes, compares and other available data.
g. Seeks out growth opportunities.
h. Able to work as a team member.
a. Obtains, receives and delivers information in a professional and meaningful manner.
b. Written communication is descriptive and to the point.
c. Verbal communication is professional and complete.
a. Collaborates and coordinates patient care with other disciplines, agencies, vendors, providers, physicians and payers.
b. Takes responsibility to stay informed and provide information to others.
c. Makes referrals with follow through to provide the best outcomes for the patient.
a. Meets legal, regulatory and organizational requirements.
b. Is objective and unbiased, provides enough detail to allow accurate interpretation of data presented.
c. Professional with use of professional terms and abbreviations.
d. Is descriptive of care provision, assessment, intervention and response.
e. Is completed within timeframes.
a. Demonstrates competent level of physical, behavioral, functional and cognitive assessment.
b. Assesses through observation, interview and other resources.
c. Assesses learning abilities of patients and caregivers.
d. Able to identify barriers to care and learning.
e. Demonstrates ability to perform age appropriate and cultural appropriate assessments.
f. Has a clear, concise and competent understanding and use of OASIS tool.
7. Care Planning
a. Care planning is based on patient assessment.
b. Care planning incorporates barriers and learning abilities of patient and caregivers.
c. Care Plan Goals reflect priorities of the patient and are measurable.
d. Interventions are action specific describing the action desired of the nurse, caregiver or patient.
e. Interventions include a -to be completed by- date or time frame.
f. Care plans reflect coordination of care, referrals to other disciplines or agencies.
g. Care plans are updated, revised and current.
h. Includes patient teaching, reinforcement, specific directions for hands on care to be provided and discharge plan.
a. Able to provide age and cultural specific care.
b. Able to perform nursing tasks and skills as necessary.
c. Secures, organizes, integrates and modifies resources required to provide the best outcomes for patient.
d. Provides care with use of critical paths, disease management guidelines, best practice use.
e. Attempts to reduce or prevent re-hospitalization of patient through early recognition and intervention of symptoms
General duties as directed.