- Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values.
- Serves as primary nurse and case manager, coordinating all members of the interdisciplinary team in providing high quality Hospice care.
- Must be empathetic, responsible, able to use time effectively, and willing to work with a team.
- Assess the needs of patients based on initial referral evaluation, nursing assessment and review of any diagnostic data.
- Assessment of patient is completed in a timely manner as requested by family or physician within 24 hours of admission 90 percent of random observation.
- During admission of patient, the nurse assures all required forms/contracts are signed by patient/primary caregiver.
- Completes ongoing assessments of the patient per Plan of Treatment and more often as indicated by condition changes, 90 percent of random observations.
- Assesses and evaluates patient problems appropriately when patients/families utilize the "on call"System, 90 percent of random observations.
- Develops a plan of care based on problems described/observed during the initial evaluation and nursing assessment.
- Develops and completes initial care plan based on assessed needs and procedures according to departmental policy and procedures, 90 percent of random observation.
- Informs and coordinates all interdisciplinary team members in developing a comprehensive plan of care within two days of each patient's initiation of care, 100 percent of random observation.
- Documents participation of patient/family in the development of the plan of care.
- Updates the plan of care at least every 15 days in accordance with physician orders and in conjunction with the patients documented and observed changes in condition, 90 percent of random observation.
- Reviews the plan of care with the interdisciplinary team during patient care conferences
- Provides appropriate care interventions consistent with the written plan of care which reflects
- the physicians prescribed medical plan.
- Follows the plan of care during visits and identifies the frequency of home visits needed with activities directed toward meeting established goals, 90 percent of the time.
- Monitors care of the patient provided by family members, and instructs them in all aspects of patient care, medication administration, equipment use, etc.
- Informs Patient Care Manager of changes in the patient's condition and/or home situation.
- Obtains medical information from other medical professionals or facilities, according to department policy, to assure that the Hospice Team is apprised of the patient's total medical condition.
- Effectively utilizes appropriate care interventions when patients/families utilize the "on- call" system, e.g. telephone support, home visit, 80 percent of the time.
- Effectively performs nursing skills and techniques in a competent manner.
- Serves as a case manager and interdisciplinary coordinator leader for each of her assigned patients, coordinating all members of the interdisciplinary team in providing high quality Hospice care.
- Attends team conferences and relays pertinent information to Patient Care Manager to facilitate
- the reporting process to each interdisciplinary team member involved in the care of his/her
- *Recognizes signs and symptoms of the actively dying patients & communicates this information
- to team members.
- Evaluates the needs of each patient assigned and assists the Patient Care Manager in directing the flow and frequency of nursing and Home Health aide visits.
- Keeps Patient Care Supervisor up-to-date and informed of patient/family needs and problems noted by the interdisciplinary team.
- Supervises the Hospice Aide every two weeks as indicated by departmental policy, 90 percent of random observation.
- Participates in maintaining 24 hours/day, 7 days/week availability of an RN by taking "call" as Scheduled.
- Participates in Hospice activities as requested, 80 percent of the time.
- Coordinates inpatient care, respite care, continuous care and routine home care.
- Completes documentation and other assignments in a timely manner.
- Completes and locks electronic documentation of services provided, updates in plan of care any changes in patient's condition within 48 hours of routine or on-call visits, and within 24 hours of an admission visit.
- Electronically documents changes in medication records immediately as they occur, and designates coverage of meds as agency covered vs. not covered by Hospice.
- Electronically enters physician orders on the day received and makes appropriate selection on how the physician order should print, as an interim order or to print on plan of treatment.
- Synchronizes laptop computers twice daily according to established procedure.
- Responsible for transfer summaries, discharge summaries, patient care conference notes, physician orders, lab results and all required medical records & documentation pertaining to coordination of care.
- Accurately documents detailed review of systems at each nursing visit.
- Represents the Hospice Department to patients, families, team members and to the community in a positive and professional manner.
- During home visits, assessments are completed in a calm, reassuring and professional manner, 90 percent of random observations.
- Presents a positive attitude to patients, families, and Hospice Team Members, in the home and in the office. No more than 2 complaints in a year made by patients/families/Team Members that are evaluated by the Patient Care Manager and considered justified.
- Receives assignments, and instructions from the Patient Care Manager with an attitude of cooperation and team spirit, 90 percent of random observation.
- Follows Departmental Dress Code and maintains a clean, neat, professional appearance 90
- percent of the time.
- Is Reliable in terms of Attendance and punctuality. Follows departmental guidelines in requesting time off, whether scheduled or unscheduled.
- Demonstrates continual professional growth.
- Attends 20 hours of continuing education annually, including all mandatory training.
- Establishes and strives to obtain professional growth objectives as determined through annual
- Keeps informed of all new policies and procedures.
Patient Population Served:
- Recognizes the normal signs (growth and development of aging) of the patient population served and understands the requirements of assessment, treatment, and care of the specific age groups(s).
- Completes annual training specific to age needs of patient population served.
- Demonstrates competence in planning for age appropriate and culturally sensitive care.
- Obtains information related to age appropriate developmental and psychosocial needs.
- Interprets information, and plans care considering use of equipment related to age, size, and
- physical ability of patient.
- Interprets information, and plans care related to family/significant other support.
- Interprets information, and plans care related to patient/family significant other education.
- Interprets information, and plans care according to patient’s religious and cultural customs.
- Interprets information, and plans care considering patient safety.
PRN As Needed
Must have active patient contact within the past year.
AGE SPECIFIC QUALIFICATIONS: All general population. The primary age served as indicated above. Age specific characteristics will be reviewed annually through age-specific computer based training. At the end of each review period, each employee will be evaluated on age-specific characteristics within the clinical area, and be able to appropriately communicate to patients and families using characteristics based on each age group served.
Current South Carolina RN License. At least one year of nursing experience. Successfully completed a nursing refresher course within the past year. Current South Carolina Driver’s License and Automobile Insurance as required by law.
Ability to lift up to 50 pounds and carry up to 25 pounds occasionally, will involve some stooping, kneeling, crouching and/or crawling, pushing and pulling with frequent standing and walking; requires manual dexterity with ability to perceive size, shape, temperature or texture; auditory and visual perception required with attention to verbal abilities and color discrimination