Follows through on less predictable problems, refers to other appropriate disciplines, updates care plans, reviews target dates and documents progress of patient towards goals involving patient/family in care, establishes teaching plans with patient/family, coordinates discharge plans, attends physician rounds on patients, and organizes and participates in patient care conferences, using information to provide continuity of patient care. Documents nursing assessments and interventions accurately, clearly and concisely, evaluates and documents patient response and outcome to nursing interventions, and gives clear, concise, complete reports on patients.