Primary Responsibility: The key responsibility for this role is chronic disease management including the diagnosis, monitoring, and development of patients' individual management plans as a senior member of the practice multidisciplinary team. To ensure nursing services are delivered effectively to the entitled patient population. To be responsible for the implementation of processes for the effective management of patients with long-term conditions using evidence-based practice. Implement and evaluate individual treatment plans for chronic disease patients.
Identify, manage, and support patients at risk of developing long-term conditions, preventing adverse effects on patients' health. Provide routine nursing care to patients as required in accordance with clinical-based evidence, NICE, and the NSF. Request and process pathology results as required. Maintain accurate clinical records in conjunction with existing legislation.
Ensure read codes are used effectively and support with achievement of QOF targets. Support patients in the use of their prescribed medicines or over-the-counter medicines (within own scope of practice). Liaise with external services/agencies to ensure the patient is supported appropriately (vulnerable patients, etc.).
Secondary Responsibilities: Provide wound care (ulcer/Doppler, etc.) to patients. Provide immunisations (childhood, seasonal, etc.) to patients. Provide Cervical Cytology screening. Chaperone patients where necessary. Support the team in dealing with clinical emergencies and safeguarding matters.
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