The Registered Nurse (RN) is a professional caregiver who assumes responsibility and accountability for a group of patients for a designated time frame. The RN renders professional care in accordance with the physician/provider treatment plan and the nursing process of assessment, diagnosis, planning, implementation and evaluation. He/She functions as a member of the interdisciplinary team, provides case management and primary nursing care to assigned patients, addressing physical, psychosocial, and spiritual aspects of care. The RN is a clinical practitioner who coordinates and implements patient care specific to the patient population served. He/She ensures that compassionate, engaged care meets or exceeds quality standards. Care is provided in an efficient and safe manner consistent with the Maryland Board of Nursing and Hospice of The Chesapeake (HOC) standard of care. Utilizes nursing skills to determine the biophysical, psychosocial, environmental, self care, cultural, ethnic and spiritual and educational needs of the patient/family/significant other to develop, implement and revise the plan of care. In doing so, performs frequent and accurate assessments, interprets and correlates finding, establishes plan of care and implements short term goals. The RN observes patient progress, records pertinent observations, implements physician and nursing treatment plans and evaluates outcomes. The RN recognizes the legal responsibilities as specified by law and abides within those responsibilities. The RN may participate in weekend, holiday, on call, and evening/night rotations.
Direct Supervisor: Clinical Manager
Next Line Supervisor:Director, Clinical Services
DUTIES AND RESPONSIBILITIES
Provides for initial nursing visit within three days of admission assessment and immediately engages with patient to develop rapport and a sense of trust. During the initial and each visit thereafter, performs appropriately timed physical assessment through observation, palpation, and auscultation, including medical stability and presenting symptoms, including accurately assessing patient's physical, psycho-social, ethnic, cultural and spiritual needs and patient's safety needs (e.g. fall risk, abuse and neglect). Consistently uses established assessment criteria for identification of victims of abuse.
Correctly identifies, communicates and collaborates on patient problems/priorities/issues based upon assessment data, establishes measurable patient goals and communicates initial/ongoing plan of care appropriately to interdisciplinary team. Recognizes changes in clinical status and reports them to the appropriate individual.
Collaborates with patient/family when developing plan of care, adjusting communication style as necessary. Establishes priority for patient care based on immediate patient condition and mutually set patient needs/expectations.
Obtains and documents a complete list of the patient's current medications and compares the medications that the organization provides to those on the patient's list.
Assists in the assessment of family needs for bereavement services following the patient's death and conveys information to bereavement staff no later than three days after death of patient.
Formulates individualized plans of care on admit for patients based on needs, strengths, limitations and goals, as needed and plans nursing care based on medical treatment schedule, nursing assessment data, identified nursing problems and patient/family participation in care. Routinely checks for new orders since last home visit and performs all nursing care under a physician's order.
Participates actively and consistently in all appropriate Interdisciplinary Team (IDT) meetings as a means of on-going assessment of patient and family needs.
Follows all prescribed and accepted standards in providing patient care, administering medications, moving/transporting/lifting patients, and documenting patient’s condition, infection control, universal precautions and discarding of medical waste, etc.
Assists with procedures and treatments according to physician's/provider's orders. Notifies physicians/providers or appropriate individual with changes in condition/adverse outcomes. Communicates relevant information to the provider, including critical test results and values. Seeks additional resources when needed and appropriate.
Consistently follows policy and procedure for all waived testing and complies with Standard Precautions for all bedside invasive procedures.
Assesses and provides ongoing educational needs and level of understanding and individualizes patient/caregiver teaching. Takes into account patient's abilities, individual learning preferences and readiness to learn. Ensures patient/caregiver teaching and patient/caregiver level of understanding and response to teaching are documented. Incorporates teaching into routine care, involving patient/caregiver. Incorporates learning needs in discharge plan.
Notifies Social Worker and/or Chaplain when appropriate.
Completes all electronic documentation in a timely manner, following appropriate protocol. Ensures that the documentation contains pertinent information regarding patient's condition, appropriate focus of treatment, response to treatment and progress towards outcome goal; that entries are legible and that patient events/occurrence reports accurately and completely and follows policy regarding notification. Uses appropriate agency forms, using approved abbreviations consistently and correctly. Does not use unapproved abbreviations.
Evaluates, treats, reassesses and documents pain as appropriate to patient condition or need and uses appropriate pain scale.
Significant status changes are identified, communicated, responded to and documented. Documents entries in the patient's record in a timely manner, per policy and procedure.
Reports patient/caregiver/employee incidents according to HOC policy.
Adapts communication style to meet population specific needs of patient. Creates a supportive environment and provides an atmosphere that supports each patient's dignity.
Ensures that all documentation is kept with the patient record. Labels, in front of the patient, any specimens taken. Ensures that all changes to documentation, including cross outs and write-overs, are initialed and dated. Completes documentation, consistently and correctly following every visit as soon as possible.
Submits accurate time sheets and activity logs as determined by current HOC policy.
Uses appropriate resources (pharmacy, drug manuals) to ensure his/her understanding of actions, interactions, side effects and proper administration. Recognizes and reports adverse drug reactions per policy and procedure. Recognizes and reports medication variances per policy and procedure.
Accurately transcribes physician orders as per policy and procedure and places all information on the appropriate forms. Reads back orders to provider that are called in.
Attends at least 80% of staff meetings. Actively participates in team meetings by being prepared with patient's current status and with appropriate completed forms. Always reads and initials minutes and demonstrates knowledge of content for all attended and unattended meetings.
Demonstrates problem-solving skills with patients, their family, employees, other departments, visitors and others as indicated.
Maintains open and professional communications with all staff. Intercedes as necessary to promote positive, constructive interactions between staff members/departments/others. Reports issues to immediate supervisor.
Consistently demonstrates empathy in interactions with patient/caregivers.
Makes appropriate referrals to other modalities/disciplines.
Develops an effective working relationship with representatives from other agencies who provide services for assigned patients. Makes community referrals appropriately.
Demonstrates responsibility for scope of position/own standard of practice. Maintains required skills, licensure, regulatory requirements, and credentials needed to perform assigned duties.
Demonstrates full knowledge of current position's, and department's, relationship to flow of patient services and/or care plan of the patient. Demonstrates understanding of all other services of the organization.
Possess a current Maryland nursing (RN) license and thorough knowledge of nursing Principles, BSN preferred.
2-3 years of nursing experience in a medical/surgical or homecare setting required, with previous experience in hospice and/or clinical case management preferred.
Experience working effectively with Electronic Medical Records.
Demonstrated ability to provide quality patient care. Possess ability to assess patient’s needs, e.g. physical, teaching, mental and spiritual.
Must be able to perform the essential functions of the position with or without reasonable accommodation.
Ability to recognize safety issues to self and others and be able to assess and implement use of lifts or other personnel to lift and move patients of all sizes and weights in a safe manner.
Ability to perform consistently in stressful situations.
Strong and creative, problem-solving skills with the ability to prioritize and delegate.
Basic computer skills, to include but not limited to Microsoft Word and Outlook, required.
Demonstrated commitment to quality, timely, and cost-effective patient care.
Ability to simultaneously handle multiple assignments and projects with attention to details, efficiency and accuracy and deadlines.
Must be able to lift and move up to 50 lbs safely.
Current Maryland driver’s license and clean driving record. Reliable transportation a must.
Compliant with health screening and vaccination requirements of organization and position, including TB screening and Influenza vaccination annually.
Internal Number: HOC002
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