Key Responsibilities and Required Skills for Field Nurse

🎯 Role Definition

A Field Nurse (also called Home Health Nurse or Community Nurse) provides skilled nursing care, comprehensive clinical assessments, and care coordination in patients' homes and community settings. This role combines autonomous clinical decision-making, patient and family education, regulatory compliance (CMS/Medicare), and close collaboration with physicians, therapists, case managers, and community resources to ensure safe, effective transitions of care and positive patient outcomes.

📈 Career Progression

Typical Career Path

Entry Point From:

Staff Registered Nurse (hospital med-surg, telemetry, ER)
Home Health Aide or LPN transitioning to RN
Hospice or Community Health Nurse roles

Advancement To:

Senior Field Nurse / Lead Home Health RN
Clinical Nurse Supervisor / Field Nurse Manager
Case Manager / Utilization Review Nurse
Wound Care Specialist or Clinical Educator

Lateral Moves:

Telehealth Nurse / Triage Nurse
Occupational Health Nurse
School Nurse / Clinic Nurse

Core Responsibilities

Primary Functions

Perform comprehensive initial and ongoing nursing assessments in the patient's home, including detailed review of medical history, medication reconciliation, physical exam, wound assessment, pain evaluation, functional status, psychosocial factors, and safety risks; synthesize findings into a patient-centered care plan documented in the EHR.
Develop, implement, and update individualized care plans and goals in collaboration with physicians, interdisciplinary team members, the patient and family; ensure plans align with physician orders, nursing standards, and payer/regulatory requirements (Medicare, Medicaid).
Administer medications safely (oral, topical, inhaled) and provide advanced therapies such as IV medication administration, peripheral IV/central line care, infusion therapy monitoring, and blood draws when indicated; document medication administration and patient response in the electronic health record.
Provide skilled wound care including assessment, staging, debridement per scope, dressing selection and changes, negative pressure wound therapy monitoring, and coordination of wound care orders with physicians and wound care specialists to promote healing and prevent infection.
Manage chronic disease populations (e.g., CHF, COPD, diabetes, renal disease) through evidence-based nursing interventions, patient education on self-management, monitoring of disease-specific metrics, and timely communication of status changes to the care team to reduce readmissions and ER visits.
Conduct skilled clinical procedures in the home setting such as catheter care (Foley, suprapubic), ostomy care and teaching, enteral feeding tube care and feeding administration, oxygen therapy setup and monitoring, and tracheostomy care when within scope of practice.
Perform rapid assessment and emergency triage during home visits: identify acute deterioration, initiate life-saving measures within RN scope (BLS/ALS protocols), contact emergency services or supervising providers, and document actions taken.
Provide culturally competent, age-appropriate patient and family education including medication teaching, wound and ostomy care instructions, disease-specific teaching (diabetes management, heart failure precautions), fall prevention, and home safety recommendations to facilitate safe independent living and adherence to care plans.
Coordinate care across the continuum: schedule and communicate with primary care providers, specialists, home health aides, therapists (PT/OT/Speech), social workers, pharmacies, durable medical equipment vendors, and community resources to ensure seamless delivery of services and follow-through on orders.
Perform documentation and charting in compliance with agency policies and regulatory standards using Electronic Health Record (EHR) systems; ensure timely visit notes, comprehensive assessment information, care plan updates, and accurate billing/coding information for skilled nursing visits.
Monitor and report clinical outcomes and quality metrics (hospital readmission rates, wound healing progress, infection rates) to clinical leadership; participate in quality improvement initiatives and root cause analyses to improve patient care and workflow efficiency.
Execute safe infection control and isolation procedures in the home setting, including appropriate use of PPE, sterilization/clean technique for procedures, disposal of biomedical waste, and adherence to agency and public health guidelines to protect patients and staff.
Provide palliative and end-of-life nursing support including symptom management, pain control, comfort measures, coordination with hospice services when applicable, and compassionate communication with patients and families about goals of care.
Conduct home safety and environmental assessments, identify hazards (fall risks, medication storage issues, caregiver strain), and recommend modifications or referrals to services that reduce risk and support patient independence.
Initiate and manage telehealth visits and remote monitoring technologies as part of integrated home care, documenting virtual assessments, reinforcing teaching, and escalating concerns to in-person care or provider intervention when required.
Facilitate admissions, transfers, and discharges by assessing patients for home health eligibility, completing required documentation for payers (including OASIS assessments when applicable), communicating care needs to receiving settings, and ensuring medication and equipment are in place for safe transitions.
Ensure compliance with regulatory, legal, and ethical standards including mandatory reporting, accurate billing practices, maintaining licensure and certifications (RN, BLS), and adherence to agency policies and state nursing practice acts.
Advocate for patient needs by identifying social determinants of health, connecting patients to community resources (transportation, meal programs, financial assistance), and working with care managers to address barriers to care and adherence.

Secondary Functions

Participate in performance improvement projects, chart audits, utilization reviews, and interdisciplinary case conferences aimed at improving clinical outcomes and operational efficiency.
Mentor and precept newly hired field nurses and nursing students, providing clinical guidance, feedback, and competency validation for in-home care skills and documentation practices.
Maintain clinical supplies and portable equipment used during home visits; report equipment needs, coordinate maintenance/repair, and ensure infection control readiness.
Attend and contribute to agency training, in-services, and competency validation sessions on topics such as wound care updates, CMS regulatory changes, safety protocols, and new clinical practices.
Support clinical leadership by providing timely incident reports, trend observations from the field, and constructive recommendations for policy or workflow enhancements.
Collaborate with billing and clinical teams to ensure accurate visit coding, capture of skilled interventions, and timely submission of documentation required for reimbursement and regulatory compliance.

Required Skills & Competencies

Hard Skills (Technical)

Licensed Registered Nurse (RN) with valid state licensure and ability to practice in assigned state(s).
Strong clinical assessment and critical thinking skills for independent home visits and decision-making.
Proficiency in wound assessment and advanced wound care techniques, including dressing selection and NPWT (negative pressure wound therapy) familiarity.
IV therapy competency: peripheral IV insertion/maintenance, IV medication administration, pump programming, and central line care per agency policy.
Medication reconciliation, safe administration practices, and experience with high-alert medications.
Experience with Electronic Health Records (EHR) systems, point-of-care documentation, and knowledge of OASIS/Outcome & Assessment Information Set when applicable to Medicare home health.
Chronic disease management expertise (diabetes education, heart failure care, COPD management) and use of evidence-based interventions to reduce readmissions.
Catheter, ostomy, and enteral feeding tube management and patient teaching.
Basic life support (BLS) certification; ACLS/NI/other advanced certifications a plus depending on role.
Telehealth and remote monitoring technology use for virtual assessments and follow-up.
Infection prevention and sterile/clean technique for procedures in non-clinical environments.
Knowledge of CMS, Medicare, Medicaid, and payer documentation requirements for home health reimbursement and compliance.
Ability to perform safe patient transfers, mobility assessments, and fall risk mitigation strategies.
Strong documentation and clinical coding awareness to support accurate billing for skilled nursing services.

Soft Skills

Excellent verbal and written communication skills for clear patient teaching, provider updates, and EHR documentation.
Strong clinical judgment, prioritization, and time management to organize caseloads, respond to urgent needs, and manage travel between visits.
Empathy, cultural sensitivity, and patient-centered bedside manner to build trust with patients and families in their homes.
Ability to work independently and as part of an interdisciplinary team; dependable, self-motivated, and adaptable.
Conflict resolution and negotiation skills when coordinating care plans or addressing barriers with patients and caregivers.
Problem-solving orientation and resilience to manage variable home environments, complex clinical scenarios, and travel logistics.
Attention to detail and organizational skills to ensure accurate documentation, medication safety, and equipment readiness.
Coaching and teaching skills to empower patients and caregivers in self-management and preventive health behaviors.
Professionalism and ethical conduct, including confidentiality (HIPAA) and adherence to scope of practice.
Flexibility and willingness to work varied schedules, including occasional evenings, weekends, or on-call rotations as needed.

Education & Experience

Educational Background

Minimum Education:

Associate Degree in Nursing (ADN) or Nursing Diploma with active RN licensure.

Preferred Education:

Bachelor of Science in Nursing (BSN) preferred; specialty certificates (e.g., CHPN, WOCN wound certification, Case Management Certification) advantageous.

Relevant Fields of Study:

Nursing (ADN, BSN)
Community Health Nursing / Public Health
Gerontology or Chronic Disease Management
Clinical Education / Healthcare Administration (for advanced roles)

Experience Requirements

Typical Experience Range:

1–5 years of nursing experience; most employers prefer at least 1–2 years of recent clinical experience in acute care, home health, hospice, or community nursing.

Preferred:

2+ years of home health, hospice, community health, or related field nursing experience.
Prior experience with EHR documentation, OASIS assessments (for Medicare home health), and successful management of a caseload in an outpatient or community setting.
Valid driver's license, reliable vehicle, insurance as required by employer, and willingness to travel regionally for home visits.
Background checks, current immunizations (including TB screening), and up-to-date BLS certification required; additional certifications encouraged (e.g., ACLS, PALS, wound care specialty).