Nurse Delegation: Nursing Visit Page 2
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3Nurse Delegation:
Nursing Visit – Page 2
14. CLIENT NAME
15. DATE OF BIRTH
16. ID SETTING (OPTIONAL)
17. NOTES
18. 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)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
17)
18)
19)
20)
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 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.
19. RND SIGNATURE
20. DATE
21. 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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