The Registered Nurse uses the nursing process and evidence-based practice to collaborate with the Core Team (Patient, Provider, Nursing, and Support Personnel) and Expanded Team (family/caregiver, internal and community-based services involved in providing care to the patient) in developing the patient-driven holistic care plan for life. The Registered Nurse is a member of the core clinical team of ambulatory care. The RN is responsible for collaborating with services internal and external to the VA to facilitate care transition to effectively meet the patients' needs. The RN provides patient and family health education with a focus on self-management, prevention, and wellness, based on the patient's goals. The RN demonstrates leadership by serving as a
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