The Registered Nurse (RN) plans, organizes, and directs Agency care and administers skilled nursing care to patients on an intermittent basis in their place of residence.  This is performed in accordance with physician orders and plan of care under the direction and supervision of the Clinical Manager/Nursing Supervisor. The RN is experienced in nursing, with emphasis on community health education/experience.


  1. Graduate of an approved school of professional nursing.  
  2. Current licensure in State, CPR certification, and valid driver’s license.
  3. One (1) year of experience as a professional nurse within the last three years, with one (1) year of home health care experience preferred.
  4. Excellent observation, verbal and written communication skills, problem-solving skills, basic math skills; nursing skills per competency checklist.
  5. Acceptance of philosophy and goals of the Agency.



  1. The Registered Nurse assumes responsibility for, but is not restricted to:
  • Ongoing interdisciplinary assessment of the patient
  • Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s)
  • Providing services that are ordered by the physician as indicated in the plan of care
  • Patient, caregiver, and family counseling
  • Patient and caregiver education
  • Preparing clinical notes
  • Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care
  • Participation in the Agency’s QAPI program
  • Participation in agency-directed in-service training
  • Supervision of LPN and Home Health Aide services.

Patient Care

  1. Completes an initial, comprehensive and ongoing comprehensive assessment of patient to determine skilled nursing needs.  Provides a complete physical assessment and health history.
  2. Provides professional nursing care by utilizing all elements of nursing process.
  3. Assesses and evaluates patient’s status by:
  • Writing and initiating plan of care
  • Regularly re-evaluating patient and family/caregiver needs
  • Participating in revising the plan of care as necessary
  1. Initiates the plan of care and makes necessary revisions as patient status and needs change.
  2. Develops a care plan that establishes goals, based on nursing diagnosis and incorporates nursing actions.  Includes the patient and the family in the planning process.
  3. Initiates appropriate preventive and rehabilitative nursing procedures.  Administers medications and treatments as prescribed by the physician in the physician’s plan of care.
  4. Counsels the patient and family in meeting nursing and related needs.
  5. Provides health care instructions to the patient as appropriate per assessment and plan.
  6. Assists the patient with the activities of daily living and facilitates the patient’s efforts toward self-sufficiency and optimal comfort care.
  7. Acts as Case Manager and assumes responsibility to coordinate patient care for assigned caseload.


  1. Completes, maintains and submits accurate and relevant clinical notes regarding patient’s condition and care given.  Records pain/symptom management changes/outcomes as appropriate.
  2. Communicates with the physician regarding the patient’s needs and reports changes in the patient’s condition; obtains/receives physicians’ orders as required.
  3. Communicates with the care team and community health related persons to coordinate the care plan.
  4. Teaches the patient and family/caregiver self-care techniques as appropriate.  Provides medication, diet and other instructions as ordered by the physician and recognizes and utilizes opportunities for health counseling with patients and families/caregivers.  Works in concert with the interdisciplinary group.
  5. Provides and maintains a safe environment for the patient.
  6. Assists the patient and family/caregiver and other team members in providing continuity of care.
  7. Attends care team/case conference and staff meetings.

Additional Duties

  1. Participates in on-call duties as defined by the on-call policy.
  2. Ensures that arrangements for equipment and other necessary items and services
    are available.
  3. Supervises ancillary personnel and delegates responsibilities when required.
  4. Assumes responsibility for personal growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and in-service classes.
  5. Fulfills the obligation of requested and/or accepted case assignments.
  6. Actively participates in quality assessment performance improvement teams and activities.

The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job.  The incumbents may be requested to perform job-related tasks other than those stated in this description.


1. Supervised by: Clinical Supervisor/Clinical Manager

2. Employees Supervised: None