TAWL Health Care

Policy and Procedure Manual
Title: Registered Nurse, Staff, Field

Responsible for the provision and documentation of professional nursing services to agency clients in accordance with an established physician plan of care and in compliance with applicable licensure / certification requirements, the state Registered Nurse Practice Act and the agency's policies and procedures.

1. Registered nurse with valid licensure through the Texas State Board of Nursing.
2. One (1) year of clinical nursing experience in acute care setting with exposure to geriatric client care and / or in an adult medical / surgical setting preferred. One (1) year of experience in a home health agency staff nurse position preferred.
3. Excellent verbal and written communication skills.
4. Valid driver's license in the state of Texas, available and dependable transportation and proof of current automobile liability insurance.
5. Ability to meet minimum agency hiring standards which include evidence of current cardiopulmonary resuscitation (CPR) certificate and willingness to perform such procedures in the home setting.
6. Essential physical, mental, and / or environmental working conditions:
a. Must be able to meet the physical demands which including standing, walking, bending, lifting, and transferring.
b. Must be able to utilize good judgement, demonstrate patience, and maintain a professional demeanor.
c. Must be able to work in a busy and stressful environment.


1. Performs client admission assessment and manages / coordinates all aspects of services delivery.
a. Makes initial nursing evaluation visit, completes a thorough nursing assessment and documents findings accordingly.
b. Develops client care plan and plan of treatment within 24 hours of admission visit.
c. Establishes realistic and measurable client goals.
d. Revises care plan on a weekly basis or as needed.
e. Communicates and involves other disciplines, family and client in developing care plan.
f. Obtains subsequent orders as needed to revise care plan and plan of treatment.
g. Provides skilled nursing care in the client's home as ordered by the attending physician and commits to a minimum of five (5) visits per day.
h. Provides care according to a written client care plan and the signed plan of treament.
i. Appropriately identifies and refers clients to outside agencies for services not provided by the home health agency.
j. Supervises and guides care provided by others, including bi-monthly home care aide and LPN/LVN visits as assigned.
k. Keeps plan of care and clinical record updated and accurate as new orders are written.
l. Communicates with physician regarding any condition change and client's progress or lack thereof.
m. Maintains a thorough record of nursing observations and client care activities in each clinical record.
n. Completes accurate and timely clinical documentation and submits according to agency established policies and procedures.
o. Takes on-call responsibilities as assigned by agency and gives concise reports according to established procedure.
2. Demonstrates clinical competency in areas of assigned nursing responsibility.
a. Exhibits knowledge of technical skills required to implement safe nursing care and health promotion of homebound clients.
b. Verifies medication orders and client knowledge of such orders.
c. Reports all adverse drug reactions to physician and nursing supervisor or coordinator.
d. Demonstrates knowledge of safe usage of client care equipment by following established policy.
e. Recognizes and corrects or reports to appropriate person any unsafe situation or safety hazard in the home immediately.
f. Carries out procedures in accordance with infection control policies at all times.
g. Observes universal precautions when caring for all clients.
h. Practices isolation techniques according to established policies and procedures.
i. Practices good body mechanics when lifting or transferring clients or equipment.
j. Demonstrates good safety control of all medical equipment.
3. Promotes positive and professional approach to clinical responsibilities and seeks to enhance skill level on a regular basis.
a. Maintains good rapport with all client care personnel and other disciplines requiring frequent interaction and coordination of client care.
b. Addresses clients, families and co-workers in a responsive and respectful manner.
c. Consistently projects the agency's positive image in all client business and community interactions.
d. Demonstrates commitment to the maintenance of positive and effective working relationships with other agency personnel.
e. Responds to clients with empathy and positive interpersonal skills.
f. Consistently handles all requests in a positive manner.
g. Maintains professional appearance in accordance with dress code policies.
h. Provides accurate, necessary and / or requested information to clients and families in an appropriate manner.
i. Demonstrates knowledge of and compliance with established agency nursing policies and procedures.
j. Complies with all local, state and federal regulations and JCAHO guidelines regarding nursing and home health care qualifications.
k. Coordinates client and family education needs.
l. Documents the teaching plan of care and client progress / response on appropriate skilled note after each visit.
m. Reports abnormal findings or changes in client condition to the physician and supervisor promptly.
n. Assumes primary nurse role and acts as case manager for assigned clients, if applicable.
o. Completes and documents thorough physician assessment results concurrent with client admission.
p. Understands and carries out the nursing process as demonstrated by practice and client care documentation.
q. Evaluates response of client to care provided with regular review on a weekly basis.
r. Makes on-site supervisory visits on LPN/LVN every 60 days and home care aides every two weeks.
s. Attends no less than 95% of staff meetings per fiscal year.
5. Participates in case conference process and ensures implementation of activities recommended for improved quality of client care.
a. Participates in case conferences as requested by immediate supervisor.
b. Validates information obtained by others and includes relevant data in documenting assessment information.
c. Plans ways to solve problems, meet needs and make improvements in the quality of client care.
d. Promotes self-care and independence in care by client and family members and utilizes community resources.
e. Manages a caseload of clients and effectively communicates with other staff in order to keep them informed of changes in the
client's condition or the physician orders as necessary.
f. Participates in CQI process as directed.
6. Demonstrates awareness of agency financial and productivity goals in the promotion of effective and efficient agency operations.
a. Demonstrates flexibility in work assignment and personal accountability in meeting the staffing needs of the agency.
b. Willngly floats to other branches to assist or cover as requested.
c. Conveys an attitude of support for home health and its established policies.
d. Generates enthusiasm for and actively supports the staff effort in providing quality health care.
e. Respects client and staff individual right to confidentiality of information.
* Since it is difficult to identify all essential functions of a job because of changes in the workplace, this job description will be reviewed periodically to ensure it is accurate and up-to-date.*

I understand I am not eligible for employment if I have ever been convicted of a criminal offense or under criminal indictment / charge of an offense that did or would have endangered a client or fellow employee or property of a client, employee or employer.

I have read and understand this job description and agree to the condition set forth herein.