Overview
The Registered Nurse is responsible for assessing clients’ health to determine their level of care and services, by qualified caregivers.
Duties and Responsibilities
Assessment:
The RN assesses clients and identifies variables that may affect client care and services provided. The RN updates the Care Plan as needed or annually.
Assists in identifying a wide range of problems and in determining and prioritizing the client’s care.
Responsible for supervising and assessing the performance of caregivers, licensed and non-licensed.
Assists in addressing existing and potential client/family problems.
Assists in interpreting data and assures that findings are communicated to the physician in a timely manner and documented appropriately.
Planning:
Ensure the family and client has been involved in the development of the plan of care.
Ensures the family input was considered in the development of the nursing care plan
Ensures that services needed to facilitate care of the client is being utilized
Ensures that optimal standards of nursing care are being met consistently and appropriately
Ensures that optimal nursing care reflects awareness of legal responsibilities and consequences of nursing actions
Ensures that proper referrals to other professionals are utilized (i.e.) (physical therapist, occupational therapists, etc.).
Implementation:
Addresses all family/client complaints verbally and in writing after carrying out a thorough investigation.
Makes sure that client/family needs are responded to appropriately
Performs care during client assignments in the home visits should include, but are not limited to:
Give families a chance to voice complaints and respond appropriately to the resolution of the complaint.
Actively listens to clients and families.
Assesses nursing/client interaction and/or client/family interaction.
Assesses the environment for safety and cleanliness and makes recommendations.
Assesses infection control practices including proper hand washing.
Review the nursing care plan for accuracy, completeness, and makes sure it is updated properly.
Makes sure that documentation is done accurately and appropriately in the progress notes.
Checks to make sure medications are signed off; treatments are done, documented and signed off in the records.
Makes sure physician’s orders are updated as required and are transcribed properly.
Ensures that equipment is being properly maintained and cleaned to prevent the spread of infection.
Ensures that necessary supplies are available.
Makes sure that emergency protocols are in place.
Reviews the communication book for relevant information.
Ensures that family knows the agency is available and can be contacted at any time.
Physically assesses the client and their well-being.
Ealuation:
Assists in evaluating clients’ responses to the plan of care
Ensures that the plan of care is revised as needed in response to changing needs
Ensures that on-going communication between nurses and physicians exists
Evaluates staff performance and update skill validation competency as required by the agency.
Administratie:
Schedule home assessment directly with clients
Verify assessments for accuracy, scan, and upload to EMR.
Provide any necessary medical follow-ups.
Update any medical related documentation I.E assessment trackers