The Home Care Field RN is a professional caregiver who is a member of the interdisciplinary team. Responsibilities include the coordination and provision of direct and indirect patient care using the nursing process to meet the physical, psychosocial, environmental, and spiritual needs of Carle Home Services specific patient populations and families throughout the geographical area. Demonstrates understanding of Medicare Home Care benefits including covered services, recertifications, transfers, and non-recertifications. Follows regulatory requirements regarding documentation standards. Comprehends department specific indicators. Performs case management activities of assessment, coordination, planning, monitoring, implementation, and evaluation. Interacts with clients, caregivers and families to assess, plan care, arrange services, monitor, and provide support and education. Consistently completes all admission documentation within policy guidelines. Returns admission documents to office complete and in a timely manner (according to policy). Completes required OASIS/485 changes within 24 hours of receiving them. Completes visits notes and telephone conversations records and transmitted timely according to policy (includes physician orders, admission, routine, supervisory, telephone and discharge notes.) Ensures Physician Orders are written timely, corrections to care plans are entered and transmitted according to time line. Reviews verbal orders with MD office, written and evidenced as read-back, completed immediately and transmitted within time frame established by policy. Once documented and transmitted orders are never changed. Ensures patient visit string(s) are added to the record to make sure visits are not missed. Ensures proper acronym is evident on all physician orders. Completes Home Health Aide supervisory visits. Acts as the coordinator of the health care team in order to maintain the proper linkages within the continuum of care. Collaboratively communicates and initiates case conferencing as necessary and documents interacts (other disciplines, MD, care coordinator, insurers, etc.). Communicates pertinent information for patient care conferences on all admits done by him/her. Practices in a manner sensitive to the needs of patients and families. Provides care according to plan of care and orders. Directs the activities of the licensed practical nurse. Makes home health aide assignments, prepare written instructions for the aide and supervises the aide in the patient home. Demonstrates adequate knowledge of State and Federal regulatory and accreditation guidelines which is evidenced by daily performance. Perform OASIS assessments for admissions, recertifications, resumptions and discharges. Performs complex wound care including wound vacs, packing, removal of staples or sutures. Monitors central lines including PICC and Hickman catheters and performs dressing changes per agency protocol. Accesses mediports for IV infusion and/or blood draws and flushes per agency protocol. Performs case management for patients assigned to her/his case load. Communicates with MD per phone or electronically regarding patient updates and condition changes.