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in Worcestser, MA

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About this job

Essential Job Functions/Responsibilities:

Patient Care:

  • Completes an initial assessment of patient and family to determine home care needs.  Provides a complete physical assessment and history of current and previous illness (es).
  • Regularly re-evaluates patient nursing needs.
  • Initiates the plan of care and makes necessary revisions as patient status and needs change.
  • Uses health assessment data to determine nursing diagnosis.
  • Develops a care plan which establishes goals, based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions.  Includes the patient and the family in the planning process.
  • Initiates appropriate preventive and rehabilitative nursing procedures.  Administers medications and treatments as prescribed by the physician.
  • Counsels the patient and family in meeting nursing needs.
  • Provides health care instructions to the patient as appropriate per assessment and plan.
  • Identifies discharge planning needs as part of the care planning development upon admission.

 

Communication:

  • Prepares clinical notes and updates the primary physician at least every sixty days and/or as needed.
  • Communicates with the physician regarding the patient’s needs and reports and changes in the patient’s condition; obtains/receives physicians orders as required.
  • Communicates with community health related persons to coordinate the care plan.

 

Additional Duties:

  • Participates in on-call duties as defined by the on-call policy.
  • Ensures that arrangements for equipment and other necessary items and services are available.
  • Instructs, supervises and evaluates home health aide care provided every fourteen days.