-

A. Demonstrates ability to process paperwork and associated functions necessary to facilitate :

1. Knowledge of Assessment Process :

a. Health history and psychosocial history

b. Development of problem list

c. Assists in the development of care plan

d. Assesses response to treatment

e. Establishes and revises goals

f. DC planning

g. Conducts complete initial evaluation

h. Other :

2. Documentation Skills: (accurate, timely, complete and legible) :

a. 485, 486, 487

b. Progress notes, flow charts

c. Summary reports

d. Incident/variance reporting

e. Other :

3. Adheres to POC :

a. Reviews POC prior to care

b. Performs services as ordered

c. Documents according to POC

d. Communicates/coordinates as appropriate

e. Other :

4. Knowledge of Medicare/State Home Health Guidelines :

a. Criteria for participation

b. Skilled reimbursable visit

c. Other :

5. Reports and documents key information to Physician, DC Planner, Clinician, Pharmacist, Supervisor

6. Submits written summary reports as indicated

7. Attends/participates case conferences as required

8. Infection Control Practices :

a. Hand washing

b. Personal protective equipment

c. Exposure control plan

d. Equipment care, as appropriate

e. Other :

9. Patient home safety

10. Other :

B. Patient Education

1. Determines learning needs

2. Sets objectives

3. Develops/implements teaching plan

4. Evaluates effectiveness of teaching

5. Revises teaching plan

6. Documents patient response

7. Other :

C. Assessment and Evaluation

1. Psychosocial assessment (social Hx., living situation, career, hobbies, support systems, decision making, communication difficulties, flexibility, prolonged mental illness/emotional problems, lack of community/ caregiver support, family discord, ability to deal with loss)

2. Financial assessment (income, ability to meet needs, management)

3. Emotional assessment (response to illness, status, need for care, response to treatment)

4. Spiritual assessment (beliefs, practices, religion, role in care)

5. Terminal care assessment: Ability to cope with death at home, patient/ caregiver receptive to hospice, concurrent life crisis, active grieving process, dependent family members, assistance needed with bringing closure to life

6. Other :

D. Skilled Treatments/Interventions

1. Counseling for long range planning and decision making

2. Community resource planning and information

3. Short-term therapy related to illness

4. High risk intervention/patient safety risk

5. Arranges for long term care

6. Other interventions

7. Other :