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The position involves providing social work services to individuals or groups, which includes screening, psychosocial assessment, discharge planning, and determining social work goals. The role requires a substantial degree of professional judgment to recognize deviations from usual patient/family functioning, anticipate problems, and maximize coping capabilities. The social worker will conduct initial assessments, establish and follow a plan of care, and provide ongoing assessments of patient/family needs, applying appropriate interventions and updating the plan as necessary. The position also involves planning for discharge from medical social services, implementing interventions, coordinating with other healthcare team members, and collaborating with community agencies to ensure continued care. Documentation of activities and maintaining patient records according to guidelines is also a key responsibility. The social worker will provide education regarding Advance Directives and communicate effectively with patients, families, and healthcare teams to resolve issues impacting continuity of care. Support for family members in the case of a patient's death and establishing professional relationships within the community are also essential aspects of the role.