Registered Nurse - RN at Professional Case Management summary: As a Registered Nurse, I provide direct patient care, assess and evaluate health statuses, and collaborate with healthcare teams to create realistic care plans. My role also involves educating clients and families, ensuring a safe home environment, and adhering to established safety and infection control practices. I continuously engage in professional development and maintain detailed client records to support quality care. Qualifications
- Graduate of a state-approved school of professional nursing.
- BSN preferred
- Current, unrestricted license as a Registered Nurse in the state(s) of practice
- Reliable means of transportation
- Current CPR certification
- Strong communication and interpersonal skills Essential Functions/Areas of Accountability
- Initiate actions independently and responsibly to improve the quality of client care Perform client visits as assigned to provide skilled interventions with a focus for achieving realistic client outcomes within a specified time period
- Provide direct care and assign and/or delegate functions according to education and demonstrated competence
- Act as client advocate
- Assess and evaluate health status of assigned clients:
- Collect objective and subjective client information
- Analyze, report and record data
- Validate, refine and modify data
- Utilize all data to identify and document current health care needs of assigned clients
- Collaborate with client, family/others, and other members of the healthcare team to identify client needs, and establish realistic goals of care
- Review plan of care on a regular basis to evaluates client response to plan, prioritize needs and modify plan to meet client's current needs:
- Cultural, ethical, spiritual aspects and decisions regarding treatment
- Plan interventions to support human functions and maintain hygiene in a comfortable and safe environment
- Align with community resources as indicated for appropriate care
- Verify medical orders are accurate, properly authorized and without contraindication.
- Administer prescribed medications and IV therapy or provide client/family/other education regarding self-administration.
- Develop, initiate, and document plan to provide client/family/other education and counseling.
- Evaluate home environment and initiate plan to ensure a safe environment.
- Institute standard policies and procedures to stabilize clients in an emergency situation.
- Demonstrate competence with technical nursing skills according to personal and legal scope of practice:
- Assessment skills as applied to the client, family/support system, and environment
- Teaching/counseling skills
- Realistic and measurable goal setting
- Evaluate client's medications for potential interactions, duplication, adverse effects and non-compliance
- Initiate appropriate preventative and rehabilitative nursing procedures
- Practice nursing with respect for individual, cultural, and spiritual differences
- Communicate interventions and client response to interventions effectively and in accordance with Agency requirements
- Report significant changes in client condition and needs to physician and other members of the team in a timely manner
- Maintain client records and clinical notes, showing systematic assessment, planning intervention and evaluation
- Coordinate services for the client as needed
- Participate in team meetings and clarify individualized reporting responsibilities with all new assignments
- Document legibly and according to Agency documentation guidelines and standards
- Maintain confidentiality in all aspects of the job Promote personal safety and a safe environment for clients and coworkers
- Demonstrate knowledge of safety/infection control practices by complying with established policies and procedures
- Recognize and respond appropriately to potentially unsafe situations
- Demonstrate safe practice in the use of equipment
- Assess environmental safety and take initiative to prevent accidents and promote safety
- Evaluate the home for its suitability for client care
- Notify case manager of need for review and/or training related to equipment, procedures, safety or infection control practices
- Initiate delegation of tasks to only those with verified skills and only for clients that are stable and where the outcome of the delegated task is predictable:
- Consider complexity of care, educational preparation and Agency policies when delegating care
- Remain responsible for all delegated acts
- Delegate/assign duties as specified in Agency regulations
- Initiate and assist with delegated care
- Participate in ongoing, professional self-development:
- Participate in all mandatory education per Agency guidelines
- Participate in supervising and teaching other nursing personnel as required
- Identify needs for personal professional growth
- Demonstrate competence in areas of assignment or identifies the need for additional training
- Perform other duties as assigned Keywords: Registered Nurse, Patient Care, Healthcare, Nursing, Client Education, Health Assessment, Care Planning, Medication Administration, Collaboration in Healthcare, Clinical Documentation