Hospice-RegisteredNurse-CaseManager

**JOB SUMMARY** The registered nurse plans, organizes and directs/coordinates home care services and is experienced in nursing, with emphasis on community health education/experience. The professional nurse builds from the resources of the community to plan and direct services to meet the needs of individuals and families within their homes and communities. **DUTIES & RESPONSIBILITIES** **Patient Care** Develops a written plan of care for each patient on caseload; Updates and initiates the plan of care and assumes responsibility for the **_ongoing_** interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s). Assesses patient’s condition, initiates plan of care, re-evaluates and updates as necessary. Initiates proper preventative and rehabilitative nursing procedures and provides services that are ordered by the physician as indicated in the plan of care; Provides skilled nursing care. Provides patient, caregiver, and family counseling. Provides patient and caregiver education. Prepares clinical notes. Communicates with the physician who is responsible for the plan of care and other health care practitioners (as appropriate) related to the current plan of care. Obtains all necessary physician orders and collaborates with physician as patient’s needs dictate. 75% of all charting to be done in the patient’s home. Attends case conferences to discuss multidisciplinary team responsibilities, patient progress, plans for continued care, new problems, etc. Re-evaluates the need for continued care on an ongoing basis; initiates recertification as necessary. Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. * Prepares clinical notes and updates the primary physician when necessary and at least every sixty days. Communicates with the physician regarding the patient’s needs and reports any changes in the patient