RN Medical Records Project

4 weeks ago


Seneca SC, United States Prisma Health Full time

Inspire health. The hospice registered nurse utilizes the nursing process to provide hospice and palliative care to the terminally ill patient, regardless of their age, and supportive care to the patient's family in the Hospice House.
Adheres to all compliance and policy and procedure requirements of the organization including, but not limited to: licensure renewal, assigned training, employee health screenings, time and attendance policy, dress code policy, patient confidentiality, infection control, medication administration. Demonstrates knowledge of regulatory agency requirements (The Joint Commission, DHEC). Provides care within the scope of the SC Nursing Practice Act.
Assessment and Planning
Assesses patient physiological, psychosocial, developmental, environmental needs, and the
families' need for supportive care. Considers the physical, emotional, and spiritual aspects of the
input into the interdisciplinary Plan of Care based on assessments. Documents assessments in the medical record .
Develops an individualized nursing and a CNA plan of care, as needed, seeking input from the
Monitors and updates the plans of care, as needed, due to changes in status
additional services and refers to other members of the hospice team.
Develops a plan of care for the time of death that meets the express wishes of the patient/family.
Implementation
Performs appropriate nursing interventions with thorough and timely documentation in patient's
Utilizes standing orders and medical authorization guidelines to guide practice.
Oversees CNA's performance of the Plan of Care according to requirements.
The evaluation process is reflected by patient's response to any treatment and/or medication administered, patient's disease progression and family's response to change, patient's progress toward goals and achieved outcomes, patient/family response to teaching, family caregiver's potential and current ability to cope with the physical and emotional demands of their role in patient's care, and cultural needs and/or developmental needs. 
Understands the importance of continued support for the family during the process of bereavement through bereavement follow-up with patient's family, supporting the bereavement POC, attending funeral, visitations or memorial services whenever possible, and attending scheduled bereavement program events, supporting those families served. Facilitates continuity of care with other team members and other agencies through accurate and
Communicates on a regular basis with all staff/volunteers
ensure quality care. Provides ongoing communication with all Hospice team members. Communicates verbally and in writing with pharmacy, DME vendors, material management and insurance
companies to help control agency costs.
Documents all clinical findings, interventions, physician orders, changes in the Plan of Care, telephone calls, team conferences and referrals.
Participates in review of quality data and makes appropriate recommendations for improvement.
Works on various projects and committees as requested.
Assists with the orientation and training of students/new employees/Volunteers.

This is a non-management job that will report to a supervisor, manager, director or executive.

Associate's Degree- Nursing

No experience required.
2 years- Acute Care Nursing is preferred.

Required Certifications/Registrations/Licenses
Experience in hospice or other home care services- Preferred 


Work Shift
Hospice Of The Foothills

Facility
1067 Hospice - Upstate

10686050 Nursing Service

Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.


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