1. Performs assessments appropriate to functional status, diagnosis, care setting, age, development level, and cultural and religious orientation in a timely manner.

2. Identifies and prioritizes the need for further assessment based on the patient’s clinical presentation/diagnosis, care setting, desire for care and responses to any previous care.

3. Initiates discharge planning for each patient upon admission as appropriate.

4. Performs interventions based on the Interdisciplinary Plan of Care.

5. Demonstrates the ability to effectively communicate patient care needs to all members of the multidisciplinary health care team.

6. Conducts patient/family education that is specific to continuity of care and includes the family/significant others when appropriate.

7. Documents interventions and patient teaching on designated forms.

8. Negotiates with physicians, other health team members, patient/family and payors to ensure optimum utilization of services.

9. Interfaces with community and procures services utilizing various community resources.