Planning - Uses assessment information and critical thinking skills to collaboratively develop individualized plan of care; actively seeks patient and family involvement to develop plan of care; collaboratively plans and prepares patients for further support; prepares patients for further support needs once the current episode of care outcomes are met (i.e., teaching, referrals, and follow-up). Job Essentials: Assessment - Performs appropriate assessment of physical, social, and psychological status (including cognitive, communicative and developmental skills as appropriate); seeks and evaluates information acquired from other members of interdisciplinary team: patient (e.g., family, physician, non-nursing disciplines, support staff).