Registered Nurse Job Description

General Function

The registered nurse (RN) is responsible for ensuring that the assessment, planning, intervention and evaluation of nursing care for the client is carried out in an appropriate consistent manner by qualified staff.

Assessment

  • The RN performs the initial client assessment and identifies variables that may affect client behavior. He/She obtain orders and updates the plan of care as needed or every 60 days.

  • Assists in identifying a wide range of problems and in determining and prioritizing the client's care.

  • Responsible for supervising and assessing the performance of other private duty nurses (LPN every 30 days) and nursing assistants (CNA every 14 days).

  • Assists in addressing existing and potential client/family problems.

  • Assists in interpreting data and assures that findings are communicated to the physician in a timely manner and documented appropriately.

  • Ensure the family and clients have been involved in the development of the plan of care.

  • Ensures the family input was considered in the development of the nursing care plan.

  • Ensures that services needed to facilitate care of the client is being utilized.

  • Ensures that optimal standards of nursing care are being met consistently and appropriately.

  • Ensures that optimal nursing care reflects awareness of legal responsibilities and consequences of nursing actions.

  • Ensures that proper referrals to other professionals are utilized (i.e.) (physical therapist, occupational therapists, etc.).

Planning

Implementation

  • Addresses all family/client complaints verbally and in writing after carrying out a thorough investigation.

  • Makes sure that client/family needs are responded to appropriately.

  • Performs care during client assignments in the home.

  • Visits should include, but are not limited to:

    • Give families a chance to voice complaints and respond appropriately to the resolution of the complaint.

    • Actively listens to clients and families.

    • Assesses nursing/client interaction and/or client/family interaction.

    • Assesses the environment for safety and cleanliness and makes recommendations.

    • Assesses infection control practices including proper hand washing.

    • Review the nursing care plan for accuracy, completeness, and makes sure it is updated properly.

    • Makes sure that documentation is done accurately and appropriately in the progress notes.

    • Checks to make sure medications are signed off; treatments are done, documented and signed off in the records.

    • Makes sure physician's orders are updated as required and are transcribed properly.

    • Insures that equipment is being properly maintained and cleaned to prevent the spread of infection.

    • Ensures that necessary supplies are available.

    • Makes sure that emergency protocols are in place.

    • Reviews the communication book for relevant information.

    • Ensures that family knows the agency is available and can be contacted at any time.

    • Physically assesses the client and his/her well-being.

Other Duties

  • Responsible for clinical duties as demonstrated in the skills competency.

  • Insures that adequate staffing for the client is done. Makes sure that the family is informed and aware of any schedule changes.

  • Is available to the private duty LPN and CNA for private consultation requiring good nursing judgment.

  • Assists the office manager in maintaining updated files on all staff.

  • Assists the office manager in maintaining all clinical files on all clients.

  • Makes sure that all records are kept confidential and filed in a locked cabinet.

Evaluation

  • Assists in evaluating clients responses to the plan of care.

  • Ensures that the plan of care is revised as needed in response to changing needs.

  • Ensures that on-going communication between nurses and physicians exists.

  • Evaluates staff performance and update skill validation competency as required by the agency. (LPN every 30 days and CNA every 14 days).

Qualifications

  • Ability to perform relevant skills

  • Current unrestricted MBON State RN license

  • Current malpractice insurance

  • Current CPR Certification

  • At least 1 year clinical experience (includes pediatric direct patient within the past 2 years)

  • A formal nursing education a college, university, or hospital that presents a certificate in the form of a bachelors degree, associates degree, or other.  

  • Criminal background check

  • Three references: two professional, one character

  • Health Clearance - Annual physical exam, TB (PPD or chest x-ray), and Hep B clearance