A skilled nurse performs a variety of duties to care and comfort for patients requiring medical services. A skilled nurse must utilize specialized skills and judgment when delivering care to patients. A skilled nurse implements and evaluates patient care while performing nursing procedures to treat and rehabilitate patients. Assuring that the safety and physical comfort of the patient are meet as well as the patient’s emotional and spiritual needs. Performing nursing procedures for which his or her training has provided the necessary skills and judgment. Assisting with the rehabilitation of patients according to the care plan directed by the physician. Observing and recording all pertinent information and reporting to the appropriate supervisor and physician.
Primary Treatments
Wound Care
Cardiac and Post-op Care
Indwelling Catheter Care
Medication Management
Patient Teaching
Skilled Nurse responsibilities:
Completes referrals and takes physician’s verbal orders as necessary in a timely manner. Channels referrals appropriately to Director of Nursing for assignment.
Makes home visits, performs physical assessment, evaluates patient’s needs and consults with physicians if necessary to develop plan of care and documentations and in timely manner.
Assesses need for additional health or ancillary services and prefers patients for service(s) when appropriate, on a timely basis.
Assesses family and home environment and makes recommendations, which will enhance patient care and promote safety.
Involves patients and/or family in developing and revising an individualized care plan including necessary teachings with realistic goals, update plane of care as goals are met or change in intervention as required and documents changes appropriately within five (5) days.
Coordinates the multidisciplinary care team and plans for patient care and documents appropriately.
Interprets the admission, discharge and other policies of the company, physician, family, other health care providers, and community as needed.
Provides clear, written, and verbal Home Health Aide and LPN assignments, updates instructions for the aides and LPNs in a timely manner and documents verbal instructions appropriately.
Provides skilled nursing care and assessments to patients in the home environments, according to the plan care and promptly revises the plan, as necessary, in consultation with the physician
and other team member. Establishes and modifies goals as appropriate.
Informs and provide progress notes to the patient’s physician and podiatrist about patients under care. When the patient’s conditions changes or there are deviations from the plan of care and submit in writing patient’s summary of care at least every 60 days.
Initiate appropriate preventive, rehabilitative, comfort, pain management nursing procedures and provides instructions to patients/caregivers, and staff in a timely manner. Follows company policies and utilizes company form in documenting forms.
Explains to the patient and family the diagnosis and the nature of the treatment consistent with
physician’s orders and plan of treatment.
Performs LPN supervisory visits to evaluate competency, if necessary. Provides skilled services and appropriate instructions to LPN and documents accordingly.
Conducts Home Health Aide supervisory visits at least every two weeks either when the Home
Health Aide is present to observe and assist or when the home Health Aide is absent to assess relationships and determine whether goals are being met.
Performs specialized care in accordance with the competencies and demonstrates initiative in learning new skills and developing competency.
Maintains assigned patient’s clinical records current including Medication Profiles, plan of care conferences (PT, OT, SLP) every three weeks from the start of therapy/care and report unusual occurrences/changes to the attention of the physician. The patient and the family are consulted and informed about all the changes in the care plan.
Completes clear, concise and accurate clinical notes which documents skilled services and other required documentation appropriately and submit on a timely basis. Utilizes only universal abbreviation.
Communicates necessary information to the Director of Nursing.
Demonstrates professionalism by maintaining high standards of clinical care and staying current
on clinical and medical issues.
Attends and participates in multidisciplinary patient case conferences to demonstrate effective coordination and continuity of patient care, as well as schedule cases to be brought to the clinical records review committee.
Conducts and documents formal and informal case conferences to demonstrate effective coordination and continuity of patient care, as well as schedule cases to be brought to clinical records review committee.
Work with patient, family and health care team members effectively to coordinate services and to promote quality care and possible patient care outcomes.
Cooperates and is reliable with providing on-call coverage and marking PRN, Weekend and holiday visits to the patients.
Establishes and maintains working relationship and open lines of communication with personnel from physician’s offices, area hospitals, clinics, etc. to assure flow on information, referrals for service and continuity of care.
Completes nutritional assessments and provides patient/caregiver instructions on diet/nutrition and seeks consultation as necessary.
Uses appropriate teaching material and techniques to obtain position outcomes and seek consultation as necessary and documents patient/caregiver outcomes on company forms.
Uses appropriate infection control procedures and safety measure.
Administrators CPR provides emergency care necessary and maintains current CPR certifications.
Assists in orienting/precepting new staff when necessary.
Provides and documents services in accordance with State, Federal, Medicare, Medicaid regulations as applicable.
Provides and documents services in accordance with third party payer requirements and obtains prior authorization as required.
Notifies data processing of payer source changes in a timely manner.
Performs job duties and uses resources appropriately.
Coordinate with Administrator/DON program to improve deficient services and the development and implementation of plan of correction. Adheres to policies and procedures of Evolve Community Services, LLC
Performs other duties as assigned by the Director of Nursing.
