RN Per Visit, Martha's Vineyard, VNA of Cape Cod

Purpose of Position

Performs a comprehensive nursing assessment upon admission of the patient including physiological, physiopsychological and environmental factors as well as health history to provide for the safety and quality of care treatment or services. Integrates all pertinent data gathered on assessment and identifies problems that form the basis of a plan of care, adhering to case management objectives.

Description

• Maintain annual HHRG values at the National Standard as appropriate.
• Utilize HHRG values to establish visit frequency and to establish appropriate interdisciplinary utilization.
• Annual outcomes meet National Benchmarks.
• Refers to community resources as appropriate.
• Evaluates the clinical needs of the patient; initiates, develops, implements and makes necessary revisions to the patient's plan of care; addresses all problems in the plan of care and documents accordingly.
• Participates in inter-disciplinary patient case conferences; evaluates effectiveness of established plan of care.
• Instructs and provides documented supervision of the Home Health Aide plan of care every 14 days.
• Notifies MD / other involved care providers of significant changes in the patient's condition.
• Completes admission and other paperwork on a timely basis.
• Records narrative documentation to reflect skilled care. Documentation is clear, concise and addresses specifics of teaching, direct care and response of patient / caregiver.
• Obtains and clarifies valid MD orders for all care delivered.
• Plans and coordinates discharges appropriately and informs patient / MD and records disposition of patient in the discharge summary. Completes all appropriate discharge paperwork.
• All other duties as assigned.

Qualifications