1. Provides initial and ongoing assessment of patients: medical, physical and psychosocial status including:
a. Obtaining relevant health and medical history from patients and/or caregivers,
b. Performing physical exam appropriate for age and history, including comprehensive functional assessment when clinically indicated,
c. Conducting preventive screening procedures based on age and history,
d. Identifying medical and health risks and needs,
e. Updating and recording changes in health status,
f. Ordering, conducting and interpreting appropriate diagnostic tests,
g. Identifying the needs of the individual family or community as a result of the evaluation of the collected data,
h. Formulating the appropriate differential diagnosis based on history, physical exam, clinical findings and diagnostic test findings,
i. Developing care plan and communicating plan to patient, the caregiver or family, and the primary care provider.
j. Identifying non-pharmacologic interventions and prescribing non-pharmacologic therapies; identifying pharmacologic interventions and prescribing pharmacologic therapies when having approved prescriptive authority from the State of Indiana,
k. Providing relevant patient education,
l. Making appropriate referrals to physicians and other health professionals and community agencies,
m. Determining the effectiveness of care plans for documentation of patient outcomes and modifying the plan as necessary to achieve medical and health goals; communicating findings and plan of care to patient, the caregiver or family, and the primary care provider.
2. Participates in quality improvement review on a periodic basis, including systematic review of records and treatment plans, helps disseminate findings and implement plans for improvement.
3. Serves as educational resource for other VAMC staff.
4. Serves as a member of various VAMC committees dealing with healthcare.
· Completes and maintains written records in a timely fashion and in compliance with VAMC rules and regulations.