ESSENTIAL DUTIES:
• Initial and ongoing comprehensive assessments of the impact of the terminal disease on the patients physical, functional,
psychosocial, and environmental needs and ADLs, i.e., risk for grief, cultural and spiritual, verbal and non-verbal
• Implement the individualized POC and recommend revisions to the plan as necessary
• Collaborates care amongst patient/patient caregiver, physicians and healthcare professionals
• Consult with and educate the patient and family regarding disease process, self-care techniques, end-of-life care, nutrition
and dietary needs
• Provide training to other staff as needed
• Initiate appropriate preventive and rehabilitative nursing procedures
• Prepare clinical and progress notes that demonstrate progress toward established goals
• Attend Inter-Disciplinary Group (IDG) meeting, coordinate and participate in the patient care planning process,
prioritization of needs and collaborates with IDG to promote coordination of patient care
• Use of case management approach and referring to other services as needed
• Inform physician and other personnel of changes in the patient’s needs and outcomes of intervention, while evaluating
patient/family response to care
• Determine scope and frequency of services needed based on acuity and patient/family needs
• Assess ability of the caregiver to meet the patient’s immediate needs upon admission and throughout care