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Transitional Care Nurse
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- The Transitional Care Nurse (TCN) ensures that identified Beth Israel Deaconess HealthCare (BIDHC) patients discharged from an inpatient setting transition safely to the patient's home/community setting.
- Complete discharge medication reconciliation, identify discrepancies or adherence barriers and accurately document the encounter in the medical record.
- Review discharge summary instructions and provide care coordination, follow up lab and diagnostic studies, specialty and primary care provider appointments.
- Provide health coaching and education to patient/caregiver on discharge summary plan of care.
- Document summary of the patient/caregiver encounter in patient's EHR according to BIDHC protocols.
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