registered nurse, home care - Poughkeepsie, United States - WMCHealth

Description

The Registered Nurse demonstrates competence by integrating theoretical knowledge with clinical experience in the care of assigned patients by independently assessing, planning, and evaluating patients andutilizing the systematic approach of the nursing process. The RN utilizes patterns of patient responses to guide practice and provides nursing care as defined by the ANA Scope and Standards of Practice, in accordance with the objectives, policies and procedures of MHRH, the NY State Nurse PracticeAct and our philosophy of nursing.
RESPONSIBILITIES
Clinical Skills and Knowledge
aCompletes a comprehensive assessment including determination of health literacy, depression screening, determination of readiness for change, assessment of patients self efficacy related to disease management.
aFollows evidence-based clinical practice guidelines incorporating principles of chronic disease management.
aDevelops and implements a plan of care based on evidence based guidelines, incorporating patient centered goals.
aUses motivational interviewing techniques to determine patients needs and health goals.
aEvaluates progress toward patient-centered goals weekly and revises plan when needed.Researches and assists in the development of patient educational tools.
aDemonstrates critical thinking skills by recognizing significant changes in the patients condition and making the appropriate interventions.
aPerforms nursing care consistent with policies and procedures of the agency and in accordance with established best practices.
aCompletes recertification OASIS on site, revising patients goals and orders to reflect clinical, functional and service needs identified through the OASIS assessment.
aUtilizes telemonitoring for patients with appropriate diagnosis to promote positive outcomes.
aOASIS documentation accurately reflects the clinical, functional and service needs of the patient.
aPatient plan of care includes the appropriate disciplines as identified and supported by the OASIS assessment.
Communication/Collaboration
aCommunicates hands-off patient information in clear, concise and timely manner via email, telephone and verbally as appropriate.
aSubmits completed Start of Care OASIS, including all required elements, within 48 hours of initial visit.
aConferences with all disciplines after initial evaluation and every 14 days thereafter and documents in the EHR.
Communicates to MD SOC information including POC, medications and pertinent assessment findings. Obtains and documents verbal order for SOC.
aDocuments patients progress legibly and according to agency policy.
aUpon transition to a different care setting (SNF, ED, hospital) provides verbal report to the accepting facility. Completes transfer form as needed and submits to Intake Coordinator.
Case Management/Leadership
aAssigns patients to LPN and per diem RN appropriately; prepares packets and updates.
aAssigns home health aide appropriately. Develops plan of care with patient and family. Orients HHA on site per protocol and completes HHA supervision every 14 days or less.
aParticipates in multidisciplinary team conferences when appropriate.Initiates multidisciplinary conferences.
aCompletes and submits activity sheets and census sheets weekly.
aPrepares patient for discharge from nursing services to case management status communicating to all disciplines and documenting in the EHR.
aCompletes discharge OASIS and discharge summary within 5 days of discharge visit. Notifies all involved disciplines of discharge and documents in EHR.
aCompletes medication reconciliation on start of care and weekly thereafter.
aPerforms and documents disease specific teaching activities including but not limited to medications.
aPerforms skin assessment weekly and documents in patient record.
aMeasures wounds weekly.Initiates consultation with certified wound specialist for patients with stage 3 or 4 pressure ulcers.Initiates consultation with certified wound specialist for patients showing no improvement in wound status after two weeks of treatment.
aObtains insurance authorization as required.
aAccepts assignments willingly.Travels to all geographical areas
aDelivers BNI (HHABN, NMN) according to policy.
Professional Development
aDemonstrates the professional role of the registered nurse role by incorporating best practices and interacting with others in a professional manner.Participates in staff orientation. Serves as preceptor to students and to new staff members.
aAccepts accountability for own practice.Identifies potential learning needs of staff. Researches and assists in the development of staff education.
Quality Improvement and Safety
aAdministers medications safely including: preparation, pre and post assessment, and monitoring of patients responses.
aPromotes a culture of safety by fostering an attitude of trust, participation and collaboration among colleagues.
aProvides input to the development and revision of nursing policies. Researches evidence-based practice supporting the policy development/revision.
aIdentifies potentially dangerous situations which could cause harm to patients/staff and suggests actions to minimize risk.
aReports incidents/ errors/critical values appropriately and within the proper time frames.
aAttends unit based QI project meetings. Actively participates and contributes meaningful information.
Experience:

• One year of acute care experience or related experience

Education:

• Graduate of an accredited school of nursing.

Licenses/Certifications:

• Current licensure in New York State as a Registered Professional Nurse.
• Certified in Basic Life Support.
• Other certifications as required in specialty area

Other:

• If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.
• Must possess excellent customer service skills.
• Must demonstrate ability to communicate effectively verbally and written.
• Must demonstrate ability to form effective working relationships with hospital personnel of all levels, to include the multidisciplinary team and both patients and families.

Associated topics: care unit, coronary, infusion, intensive, intensive care unit, mhb, psychiatric, recovery, staff nurse, tcu