Collaborates and works cooperatively with physicians and other members of the multi-disciplinary health care team in formal and informal teaching of patients and/or family about his or her disease process and wellness promotion plan and discharge planning: assesses patient/family learning needs, abilities, preferences, and readiness to learn; utilizes a collaborative interdisciplinary process to provide appropriate patient/family education; utilizes available information to evaluate the effectiveness of teaching in producing the desired patient outcomes and makes adjustments in teaching as indicated. Reviews database and nutrition screen; participates in the development of patient plan of care to include patient problems, goals, evaluations, and interventions; reports symptoms and significant changes in patient's condition to appropriate personnel; assesses, collaborates and coordinates patient's discharge planning needs and readiness for discharge with other members of the care team.