Explanation/Reference:
Explanation:
It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility to support continuity of care. Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A copy of select portions of the medical record (according to facility policy) is another form of communication and supports continuity. A physician might be asked to be involved if there are specific medical needs or orders that she believe are important, but is generally not involved. Coordinated Care