Nurse Delegation: Nursing Visit

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Nurse Delegation:
Nursing Visit
1. CLIENT NAME
2. DATE OF BIRTH
3. ID SETTING (OPTIONAL)
4. CHECK ALL THAT APPLY
Initial Client Assessment (See attached)
Supervisory Visit
Initial Caregiver Delegation
Condition Change
Initial Insulin Delegation
Other
5. CLIENT REQUIRES NURSE DELEGATION FOR THESE TASK(S):
DUE TO:
No Change
6. REVIEW OF SYSTEMS: ONLY CHECK CHANGES IN CONDITION FROM LAST ASSESSMENT.
Cardiovascular
Diet/Weight/Nutrition
Neurological
GU/Reproductive
GI
Respiratory
Endocrine
ADL
Sensory
Pain
Integumentary
Psych/Social
Musculoskeletal
Cognition
7. Notes
8. Caregiver (CG) Training/Competency (Check or date all that apply)
B.
C.
D.
E.
F.
A.
Observation or
Verbal
Record
Training
Other
CG Evaluated
Demonstration
Description
Review
Needed
Completed
(specify)
1)
2)
3)
4)
5)
9.
Check here if additional notes/caregiver name on page 2.
10.
Client stable and predictable
Continue delegation
See rescind form
I have verified, informed, taught and instructed the caregiver(s) to perform the delegated task(s). The caregiver(s) has indicated that
he/she accepts responsibility for performing the task as delegated. The caregiver(s) has been given the information on how to contact
the RND if he/she is no longer able or willing to do these task(s) or resident health care orders change.
11. RND SIGNATURE
12. DATE
13. RETURN VISIT ON OR BEFORE
To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078
DISTRIBUTION: Copy in client chart and in RND file
DSHS 14-484 (REV. 04/2013)

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