Discharge Planning: Proactively assesses discharge needs from admission, collaborating with the patient, family, social work, case management, and physicians to to line up necessary post-care services and teach them everything they need to know for a smooth and safe transition home. Clinical Observation, Documentation, and Communication: Maintains constant vigilance, systematically assesses the patient, meticulously documents findings and treatments in the EHR, and immediately communicates all significant changes to the physician and healthcare team.