As part of the multi-disciplinary Home Care team, to participate in the assessment, planning and implementation of individualised nursing interventions in the patients’ homes. To provide physical and psychological support to patients and families and to refer on to other agencies for ongoing support where required. To provide excellent communication links with patients and families and with other clinicians and services; to provide a patient-centred, holistic service.
COMMUNICATIONS & WORKING RELATIONSHIPS:
Internal:
Home Care Manager
Doctor
Other nursing colleagues
Home care allied health professionals
Non-clinical staff External:
Patients and families
Hospital staff and other clinical staff
Social workers
External:
Patients and families
Hospital staff and other clinical staff
Social workers
KEY ACCOUNTABILITIES:
Patient Care:
Conduct ongoing assessments as determined by patient’s condition
Frequently make the initial evaluation visit to the patient and provides those services requiring specialized nursing skill in accordance with the care plan approved by the doctor
Perform appropriate treatments as ordered by doctor in an accurate and timely manner
Make repeat visits to patients in their homes, to address and re-evaluate the nursing needs of patient, make or recommend revisions to the patient’s care plan
Observe signs and symptoms and reports changes in the patient’s condition to the doctor as often as needed
Form professional relationships with clients and families, and communicate information to them in a way that respects their views, autonomy and culture
Educate patients and their families about how to prevent illne and how to improve the patient’s health and wellbeing
Ensure consent for all treatment is obtained and recorded
Review and assess own clinical interventions so that an action plan can be initiated in a timely manner
Be an advocate for patients, making manager and appropriate team members aware of any concerns
Safely travel between patients’ homes and other venues on a regular basis adhering to relevant polices and guidelines
Maintain appropriate standards of confidentiality and Information governance in accordance with policy
Implement the infection control program designed to provide a safe and comfortable environment and to prevent the transmission of infection
Teamwork and organisation:
Participate fully in clinical and managerial supervision
Communicate effectively with all members of the multi-disciplinary Home Care team and support team-working generally
Attend team meetings as appropriate and ensure relevant patient information is fed back to the team
Actively participate in emergency duty, on-call and weekend working systems if and when required
Make effective use of the IT systems provided by the organisation and maintain timely, accurate and comprehensive records
Maintain a safe working environment by complying with quality and safety procedures, rules, and regulations.
To comply with all mandatory training requirements
Continuous improvement:
Keep abreast of new developments, skills and technology to ensure continuing competence in the job
Review the nursing service for quality improvement and make recommendations for changes as needed to ensure quality of services
Participate in audits as and when required
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