• Start of care with discharged patients from hosipital.
• Documented patient visits according to established standards.
• Evaluated interventions' effectiveness based on patient outcomes.
• Developed individualized care plans for patients, including home health aides and family members.
• Educated patients and families on disease processes and self-care management strategies.
• Coordinated referrals to other healthcare providers.
• Utilized electronic medical records system for data collection and analysis.
• Monitored patient vital signs and progress, revising care plans.
• Provided comprehensive patient assessments and care planning.
• Collaborated with various healthcare professionals for continuity of care.
• Assisted with medication management, wound dressing changes, and treatments.
• Supervised home health aides and certified nursing assistants.
• Documented patients' physical, psychosocial, and emotional needs.