Job Description

A field nurse is a registered nurse who develops, implements and evaluates individualized patient care plans. They act as social workers, advocate patient welfare, and serve as a liaison between patients, their families and healthcare providers.

Qualifications

A field nurse is required to have an associate or bachelor's degree from an accredited nursing school and must have 1-2 years of experience in a supervisory or administrative position. We prefer that you have worked in assisted living or home care.

Responsibilities 

• Update and revise patient health care plans as needed
• Perform initial assessment visits
• Educate patients and families about health care plans and options
• Make clinical decision for routine patient care
• Accurately document and submit medical records
• Demonstrate knowledge in medical care, such as diagnostic procedures, medications, symptoms and other treatment
• Provide emotional support to patients and families
• Evaluate and determine needs of patients
• Review lab results and notify physician as needed
• Implement physician order and other nursing procedures
• Create an environment for open communication
• Must be able to do home visits on a limited to as needed basis 
• Supervise aide visits and create care plans for the aides to follow
• Health Care supervisory or administrative experience.
• Completing patient assessments and evaluations related to need for services.
• Experience making referrals for patient services. 
• Obtaining written orders from physicians.
• Developing patient plans of care, managing changes to patient plans of care and instruction to care staff.
• Training staff.
• Performance of staff evaluations and competency determinations.
• Conduct unannounced home visits to monitor care given to clients by health care workers.

Direct Patient Care

1. Conduct comprehensive assessment of patients physical, mental, and psycho-social needs
2. Develop care plans to prevent disease exacerbation, improve outcomes, decrease risk status, and minimize hospital visits 
3. Utilizing behavioral strategies help patients adopt healthy behaviors and improve self - care in chronic disease management. Promote self - management goals.
4. Assist patients in navigating the health care system. Coordinate specialty care, follow - up on test results and other care coordination needs.
5. Follow-up with patients within 24 hours on inpatient discharge & within 48 hours of hospital visit notification
6. Ongoing evaluation and documentation of patient progress / risk status document on paper charting we will use EMR in the future.
7. Other task as needed

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