- Regularly re-evaluate the patient’s nursing needs, as part of the tour-of- duty and nursing visit.
- Make necessary revisions on the Plan of Care as patient status and needs change in collaboration with the HEALTHLINK Physician
- Initiate appropriate preventive and rehabilitative nursing procedures. Administer medications and treatments as prescribed by the physician.
- Counsel the patient and family in meeting nursing and related needs. Provide health care instructions to the patient as appropriate per assessment and plan of care.
- Identify discharge-planning needs during nursing visits. Communicate needs to team as part of the care plan development; assists in implementing prior to discharge of the patient.
- Prepare Home Healthlink clinical notes and updates the HEALTHLINK Physician when necessary.
- Prepare and submit accurate and relevant nursing clinical notes regarding patient’s condition and care given. Records pain/symptoms management changes /outcomes as appropriate.
- Communicate with the HEALTHLINK physician regarding the patient’s needs and reports any changes in the patient’s condition; obtains/receives physician’s orders as required.
- Teach the patient and family/ caregiver self-care techniques as appropriate. Provide medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
- Work in collaboration with the HEALTHLINK interdisciplinary team.
- Attend home health care conference and/or interdisciplinary group meetings as requested.
- Participate in on-call duties as defined by the on-call policy.
- Ensure that arrangements for equipment and other necessary items and services are available.
- Instruct, supervise, and evaluate care provided by the Home Care Specialists
- Assume responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in service classes.
- Fulfill the obligation of requested and/or accepted case assignments.
- Actively participates in quality assessment performance improvement teams and activities.
- Communication Skills
- Professionalism Skills
- Patient Care Skills
- Home Care
- Government-mandated benefits
- Medical benefits