The registered nurse in Home Care Works under the supervision of the Associate Director and/or Lead RN to assist in all facets of the referral process (preadmission, admission, follow-up and discharge). The registered nurse assesses, plans, implements, evaluates, and supervises individual patient care following established standards of care. Accepts assignments and travels to homes to deliver care. 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. The Registered Nurse provides on-call coverage during non-business hour of operations. • Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illnesses. Documents all care timely. • Regularly re-evaluates patient nursing needs. Reports changes in patient condition to physician. Obtain/receives physician’s orders as required. • Develops and imitates the plan of care and makes necessary revisions as patients’ status and needs change. The plan of care is based upon patient assessment and physicians’ orders. Uses health assessment data and OASIS/HIS data to determine nursing diagnosis. • Develops a care plan, which establishes goals based on nursing diagnosis and incorporates therapeutic, compassionate, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process. • Initiates appropriate preventative and rehabilitative nursing procedures. Administers medications and treatments as prescribed by the physician. • Provides on-call coverage during non-business hours. • Works with the interdisciplinary group to evaluate the appropriate plan of care and comprehensive assessment for all patients. • Provides health care instructions to the patient as appropriate per assessment and plan of care. Counsels the patient and family in meeting nursing and related needs. • Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient. • Acts as Case Manager when assigned by Lead RN/Associate Director and office/intake nurse and assumes responsibility to coordinate patient care for assigned caseload. Ensures that arrangements fro equipment and other necessary items and services are available. • Prepares clinical notes and updates the primary physician when necessary and at least every sixty days. Communicates with the physicians regarding the patient’s needs and reports any changes in the patients condition obtains/receives physician’s orders as required. Communicates with community health related persons to coordinate the care plan. • Other duties as assigned. Education • Graduate of a school of nursing - Required • BSN - Preferred Work Experience • 1 Year - acute care or public health experience, Home Care experience - Preferred Licenses and Certifications • Registered Nurse (RN) - State Licensure/Or Compact State Licensure - Licensed in State of Missouri or Kansas, depending upon designated work location. - Required Upon Hire • Basic Life Support (BLS) - Required within 90 Days • Driver's License - Valid In State - Required Upon Hire Travel Requirements • Must be able to travel between various system facilities and off-site locations as needed. - Required Skills and Abilities Essential Technical/Motor Skills • Ability to communicate clearly to patients, providers and staff. Must demonstrate precise eye/hand coordination and fine motor skills for IV procedures, blood pressure checks, injections and medical procedures. Interpersonal Skills • Displays a friendly, positive attitude and communicates with patients, families, physicians and co-workers in a professional manner. Essential Physical Requirements • Must walk, move, kneel, crouch, stoop, reach, stand, push, pull, and lift, speak clearly Must follow good body mechanics. Essential Mental Abilities • Ability to collect thorough information regarding patient's condition and evaluate effects of care. • Problem solve, manipulate numbers, adaptability, interpret data, calculate, comprehend, understand, explain, assess, evaluate short term and long-term memory. Essential Sensory Requirements • Must be able to assess patients and nursing staff by visual observation. Hear patients in person and on the telephone and be able to verbally respond. Must be able to feel to take blood pressure and pulse. Exposure to Hazards • Frequent exposure to communicable diseases, toxic substances, blood and body fluids, needle sticks and other conditions common to a medical environment. Other Skills and Abilities • Must be registered and successfully pass background check wit the Family care Safety Registry and other applicable state registries. Must be a licensed driver with an automobile that is insured in accordance with state and/or organization requirements and is in good working order. Must be willing to continue education to maintain skills and further knowledge of healthcare. Shows ability to prioritize workload independently.