Care Plan RN / LVN

JOB DESCRIPTION FOR RN/LVN Care Plan Nurse

QUALIFICATIONS:

1. Must be a graduate of state approved school of vocational or professional nursing.
2. Must have successfully completed the state board of registration or licensure and carry a current state license as a registered nurse or licensed vocational nurse.

JOB SUMMARY:

 A Care Plan Nurse in a skilled nursing facility (SNF) develops, implements, and evaluates patient care plans, ensuring residents receive appropriate and individualized care. They assess residents' needs, collaborate with the healthcare team, and monitor their progress, making adjustments to care plans as necessary. This role also involves educating residents and their families about care plans and providing support.  

RESPONSIBILITIES:

 Assessment and data collection

• Conduct comprehensive assessments: Gathering detailed information about residents' physical, cognitive, psychosocial, and functional status, as well as their health conditions, needs, strengths, goals, and preferences.
• Utilize the Minimum Data Set (MDS): Completing and submitting accurate MDS assessments within federal guidelines, which are crucial for reimbursement and quality reporting.
• Analyze resident data: Identifying patterns and potential health risks based on assessment information, such as changes in condition or triggers for further intervention, according to the American Association of Post-Acute Care Nursing.
• Coordinate with other disciplines: Seeking input from therapists, dieticians, social workers, and other healthcare professionals to develop a holistic understanding of the resident's needs. 

Care planning and implementation

• Develop individualized care plans: Creating a detailed plan outlining interventions, treatments, goals, and desired outcomes, tailored to each resident's unique needs and preferences.
• Facilitate care plan conferences: Leading meetings with the interdisciplinary team, residents, and their representatives to discuss assessments, establish goals, and collaboratively develop the care plan.
• Ensure person-centered care: Incorporating residents' preferences for daily routines, activities, and end-of-life considerations into the care plan, says CANHR.
• Educate residents and families: Explaining the care plan, resident rights, treatment options, and facility resources to foster engagement and understanding.
• Communicate effectively with the interdisciplinary team: Ensuring that the care plan is clearly understood and implemented by all team members involved in the resident's care. 

Monitoring, evaluation, and documentation

• Regularly review and update care plans: Assessing the effectiveness of interventions and making adjustments based on changes in a resident's condition, goals, or preferences.
• Document care plan activities: Maintaining accurate and timely documentation in electronic health records (EHRs), including assessments, care plans, interventions, and resident responses, notes the New Jersey State Nurses Association.
• Participate in quality improvement activities: Utilizing MDS data to identify areas for improvement and contributing to the facility's Quality Assurance and Performance Improvement (QAPI) program