Senior/Staff Nurse

Specific Scope for Community Health Team (CHT)

1.Conducts clinical assessment includes bio-psychosocial health history taking, physical examination, comprehensive geriatric assessment, assess medication competency and compliance, home environment assessment, and conduct multidisciplinary cases discussion with physician, documentation of findings for continuity of care.

2. Perform supportive nursing procedures such as wound care, continence management (urinary and bowel), venepuncture, management of tubes/devices (eg. urine catheter, nasogastric), tracheostomy care, wound dressing, stoma care, blood tests eg: Point of Care Testing (POCT) for blood glucose and other chronic disease monitoring review if required.

3. Assess and provide patient/resident, and caregiver education and training to facilitate care at home.

4. Collaborate with the interdisciplinary team and community partners to develop holistic care plans, facilitate care transitions and care coordination for patient/residents with health and social care needs.

5. Collaborate with community partners and primary care partners in co-managing patient/resident in the community through nodes like Community Nurse Post, and in patient/resident’s home, where necessary.

6. Empower patient/resident and caregivers with knowledge to manage health issues and prevent disease progression.

7. Evaluates patient/resident’s progress towards expected outcomes, including health education and treatment in collaboration with the patient/resident, their next of kin and the care team

Care Management

1. Assesses, plans, implements, and evaluates care to a designated group of patients/residents in the community.

2. Ensure patient care is delivered, implemented and monitored according to established stands of care and practice.

3. Recognizes own limitation, responds and intervenes timely to patients’/residents’ conditions in a clinically appropriate manner.

4. Facilitates referral to other healthcare personnel or community services to sustain their care in the community.

5. Collaborates and co-operates with doctors and other healthcare professionals for a smooth delivery of patient care and transition back to the community.

6. Facilitate case discussion with other nurses, doctor, and allied health professionals and community partners to develop and implement person-centred care plan.

7. Administers medications, treatments, and monitor patient’s/resident’s progress, ensuring timely follow-ups and accurate documentation.

8. Demonstrates knowledge and performs all relevant skills, core competencies and unit specific competencies as defined (refer to department scope of service and orientation checklist).

9. Serves as the patients/residents’ advocate when required.

10. Respects and protects patients/residents’ rights and confidentiality.

11. Facilitate Advanced Care Planning discussion with residents or their family members.