• Refer patient to medical specialist social services or other professionals as appropriate. • Ensure that the assessment of the patient and the direct and indirect patient care delivered is in accordance with appropriate licensing board, hospital policies, procedures and protocols, and all other professional standards of care. • Collect patient assessment data in a systematic manner, focusing on the physical, psychosocial, age, cultural, and spiritual needs of the patient. • Perform systematic physical exam and history of present illness. • Document assessment data, history of present illness, and physical findings on the appropriate medical record within established time frame. • Involve the patient/family and other healthcare providers when appropriate. • Facilitate clarification of patient and family goals of care. • Develop action plans required to meet goals. • Involve ancillary services as needed. • Participate in the assessment of the patient’s readiness to learn, identifying the educational barriers and tailor the educational process to meet the needs of the patient/family. • Ensure the process includes education about safe and effective use of medications, pain and managing pain, available resources, obtaining further care and their responsibility for their care. • Acquire and distribute educational resources tailored to the patient's needs. • Provide care coordination. • Work with all members of the health care team. • Utilize outside entities including but not limited to spiritual care when appropriate. • Provide care information at times of all transitions to the next provider. • Facilitate completion of POLST documents as appropriate. • Facilitate completion of advance directive documents as appropriate. • Provide expertise in pain management with attention to equianalgesic dose management and non-medicinal methods of pain management. • Other duties as assigned.