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