Assesses, utilizing age specific data, the patient’s physical, psychosocial, and spiritual status in a comprehensive manner. Performs initial assessment and completes required documentation within organizational standards. Performs and documents ongoing assessments including observation, physical examination, laboratory/test results, and patient response to procedural intervention. Participates in the identification and clarification of patient needs, as evidenced by participation in multidisciplinary care planning, to achieve optimal patient outcomes. Reviews and revises plan of care according to change in patient’s status. Assists other staff in the delivery of patient care, as appropriate. Incorporates patient teaching/discharge planning to promote optimal patient outcomes. Coordinates and documents appropriate discharge planning and referrals to ensure continuity of care after discharge.
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