Hospice RN Case Manager
-Provides professional triaging and nursing care by utilizing all elements of nursing process to patients after-hours.
Assesses and evaluates patient’s status by:
-Writing, initiating, following a plan of care
-Regularly re-evaluating patient and family/caregiver needs
-Participating in revising the plan of care as necessary
-Initiates the plan of care and makes necessary revisions as patient status and needs change.
-Uses health assessment data to determine nursing diagnosis.
-Develops a care plan that establishes goals, based on nursing diagnosis and incorporates palliative nursing actions. Includes the patient and the family in the planning process.
-Initiates appropriate preventive and rehabilitative nursing procedures. -Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
-Counsels the patient and family in meeting nursing and related needs.
-Provides health care instructions to the patient as appropriate per assessment and plan.
-Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optional comfort care.
-Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given.
-Records pain/symptom management changes/outcomes as appropriate.
-Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
-Communicates with community health related persons to coordinate the care plan.
-Teaches the patient and family/caregiver self-care techniques as appropriate.
-Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.
-Works in concert with the interdisciplinary group.
-Provides and maintains a safe environment for the patient.
-Assists the patient and family/caregiver and other team members in providing continuity of care.
-Works in cooperation with the family/caregiver and hospice interdisciplinary group to meet the emotional needs of the patient and family/caregiver.