2. Formulates a plan of care, including the discharge plan, utilizing assessment data and patient, family and health team input. Initiates a plan of care based on patient-specific needs, assessment data and the medical plan of care. Goals for patient are realistic, measurable and developed in conjunction with the patient/family. Considers the physical, cultural, psychosocial, spiritual, age specific and educational needs of the patient in the plan of are. Plans care in collaboration with members of the multidisciplinary team. Reviews and revises the plan of care to reflect changing patient needs based on evaluation of the patient's status.