RN Home Care Practitioner - South Shore Health

Job Description Summary

The community health nurse is a professional nurse knowledgeable in community health nursing who provides nursing care to patients in the community setting.

Job Description

1. Schedule
Completes weekly schedule and makes scheduled home visits per assignment. Schedules and prioritizes nursing visits according to client acuity and in accordance with the organization's emergency preparedness plan


2. Assessment/Documentation Admission Visit

For each admission to caseload, develops an individualized and holistic plan of care for the patient in collaboration with the patient/family/caregiver. Performs admission physical and psycho social assessment to determine appropriate plan of care.

3. Reassessment/Visit Documentation

For each visit, demonstrates the skills and judgment necessary to implement the plan of care, nursing interventions, and procedures necessary for the skilled care of the patient, as evidenced by chart review and observation. Updates the plan of care on an ongoing basis as goals are met and problems are identified.

4. Discharge/Documentation Discharge

For each discharge, documentation demonstrates improvement in outcomes or applicable variances are identified. Patients are appropriately prepared for discharge and all disciplines involved in the care of the patient are in agreement with plan.


5. Medication

Demonstrates knowledge of department policies and procedures for administering and documenting medications.Medication reconciliation is completed every visit and medication profile is reviewed and updated with changes as appropriate. DRR is run with each additional medication. Medication management is taught to each patient/family member each visit , including side effects.

6. Case Management

The case manager demonstrates responsibility and accountability for coordinating the plan of care for each patient on caseload. The patient /family is involved and participates in the plan of care. Communicates with all disciplines to insure quality of care.


7. Safety Awareness

Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. Complies with current hand hygiene and infection control guidelines.

8. Professional Development

Responds to and participates in opportunities to maintain, enhance, and promote the image of the professional nurse.

9. Leadership Development

Serves in a formal or informal leadership role

10. Advanced Clinical Skills

Responds to and participates in opportunities to demonstrate the use of individual advance clinical skills and advance clinical knowledge. Assumes overall responsibility for own professional development by incorporating knowledge of evidence-based practice and research into clinical practice

Graduate of an accredited School of Nursing.
Bachelor of Science degree in nursing from a college/university accredited by the NLN is preferred.

Minimum Work Experience
One to two (1–2) years of medical/surgical nursing experience is preferred.

Write, speak, understand English. Basic Nursing competencies.