Registered Nurse - RN at Professional Case Management summary: As a Registered Nurse, I provide direct patient care, assess and evaluate health statuses, and collaborate with healthcare teams to create realistic care plans. My role also involves educating clients and families, ensuring a safe home environment, and adhering to established safety and infection control practices. I continuously engage in professional development and maintain detailed client records to support quality care. Qualifications Graduate of a state-approved school of professional nursing. BSN preferred Current, unrestricted license as a Registered Nurse in the state(s) of practice Reliable means of transportation Current CPR certification Strong communication and interpersonal skills Essential Functions/Areas of Accountability Initiate actions independently and responsibly to improve the quality of client care Perform client visits as assigned to provide skilled interventions with a focus for achieving realistic client outcomes within a specified time period Provide direct care and assign and/or delegate functions according to education and demonstrated competence Act as client advocate Assess and evaluate health status of assigned clients: Collect objective and subjective client information Analyze, report and record data Validate, refine and modify data Utilize all data to identify and document current health care needs of assigned clients Collaborate with client, family/others, and other members of the healthcare team to identify client needs, and establish realistic goals of care Review plan of care on a regular basis to evaluates client response to plan, prioritize needs and modify plan to meet client's current needs: Cultural, ethical, spiritual aspects and decisions regarding treatment Plan interventions to support human functions and maintain hygiene in a comfortable and safe environment Align with community resources as indicated for appropriate care Verify medical orders are accurate, properly authorized and without contraindication. Administer prescribed medications and IV therapy or provide client/family/other education regarding self-administration. Develop, initiate, and document plan to provide client/family/other education and counseling. Evaluate home environment and initiate plan to ensure a safe environment. Institute standard policies and procedures to stabilize clients in an emergency situation. Demonstrate competence with technical nursing skills according to personal and legal scope of practice: Assessment skills as applied to the client, family/support system, and environment Teaching/counseling skills Realistic and measurable goal setting Evaluate client's medications for potential interactions, duplication, adverse effects and non-compliance Initiate appropriate preventative and rehabilitative nursing procedures Practice nursing with respect for individual, cultural, and spiritual differences Communicate interventions and client response to interventions effectively and in accordance with Agency requirements Report significant changes in client condition and needs to physician and other members of the team in a timely manner Maintain client records and clinical notes, showing systematic assessment, planning intervention and evaluation Coordinate services for the client as needed Participate in team meetings and clarify individualized reporting responsibilities with all new assignments Document legibly and according to Agency documentation guidelines and standards Maintain confidentiality in all aspects of the job Promote personal safety and a safe environment for clients and coworkers Demonstrate knowledge of safety/infection control practices by complying with established policies and procedures Recognize and respond appropriately to potentially unsafe situations Demonstrate safe practice in the use of equipment Assess environmental safety and take initiative to prevent accidents and promote safety Evaluate the home for its suitability for client care Notify case manager of need for review and/or training related to equipment, procedures, safety or infection control practices Initiate delegation of tasks to only those with verified skills and only for clients that are stable and where the outcome of the delegated task is predictable: Consider complexity of care, educational preparation and Agency policies when delegating care Remain responsible for all delegated acts Delegate/assign duties as specified in Agency regulations Initiate and assist with delegated care Participate in ongoing, professional self-development: Participate in all mandatory education per Agency guidelines Participate in supervising and teaching other nursing personnel as required Identify needs for personal professional growth Demonstrate competence in areas of assignment or identifies the need for additional training Perform other duties as assigned Keywords: Registered Nurse, Patient Care, Healthcare, Nursing, Client Education, Health Assessment, Care Planning, Medication Administration, Collaboration in Healthcare, Clinical Documentation