Post Date: 09/09/2020
Close Date: 10/09/2020
The Registered Nurse – Primary Care provides specialized transitions and/or palliative nursing care to identified primary care patients who will benefit from increased support and care to improve quality of life, manage and relieve symptoms, and improve psycho-social needs. Responsibilities include initial and ongoing assessments of patients, development and revisions of the plans of care, timely documentation and communication of assessments, and coordination of care with the palliative and transition care team.
Essential Position Functions
- Makes initial and on-going visits to assess patient and provide baseline and comprehensive data. Utilizes nursing process to provide patient care that is individualized, goal directed and consistent with current standards of practice.
- Identifies and communicates the needs of the patient and family to the interdisciplinary group which includes the PCP, assists with identifying goals of care, and monitors and documents progression toward goals.
- Participates as a member of the interdisciplinary group to establish and implement a biopsychosocial care plan in patients with serious, complex and/or chronic illness.
- Educates patients and families regarding disease process, pain and symptom management, and what to expect in the event of disease progression.
- Counsels patients and families regarding end-of-life issues and provides guidance throughout the trajectory of illness.
- Maintains high standards of professional practice by adhering to the ethics of the profession which includes seeking continuing education to support a goal of excellence in nursing care.
- Relates to patients and families in an open, empathetic and supportive manner while maintaining personal and professional boundaries.
- Provides hospitalized patient coordination, conducts urgent nursing visits, and obtains lab specimens as requested by PCPs.
- Works closely with PCPs and Hospice team to ensure a continuum of care.
- May include evening, night or weekend scheduling.
- Completes all documentation and work within the scheduled work day.
- Maintains standards of practice for patients enrolled in the Independence at Home Demonstration Project.
- Responsible for documentation in the electronic medical records, assuring accuracy, completeness and compliance with regulations, certification standards, legal and ethical standards per policies and procedures.
- Accepts and performs other duties as assigned