Nurse Delegation: Nursing Visit (Page 3 of 3) in pdf

Nurse Delegation: Nursing Visit Page 3

Instructions for Completing Nurse Delegation: Nursing Visit

All fields are required unless marked “OPTIONAL”.

1. Client Name: Enter ND client’s name (last name, first name).

2. Date of Birth: Enter ND client’s date of birth (month, date, year).

3. ID Setting: OPTIONAL – Enter client’s ID number as assigned by your business OR enter settings “AFH”, ALF, “DDD

Program”, “In-home”.

4. Check the box or boxes t hat apply to how you are using this form.

5. Client Requires Nurse Delegation For These Delegated Task(s): List the task(s) you are delegating and the reason

why the client needs to have the task(s) delegated.

6. Review Of Systems: Check the box for “No change” if client’s condition is unchanged from your last client

assessment. If client’s condition is changed from your last assessment, check the appropriate category box. If a

category box is checked, complete a note in Box 7 below.

7. Notes: Describe change in client’s condition in this box if a category box (other than “No change” is checked above.

8. Caregiver Training Competency:

A. List the name of each caregiver evaluated at this visit.

B. – D. Check the box.

E. Check box or insert the date for training needed or completed.

F. OPTIONAL – In this column, enter any other method of determining competency not already listed.

9. OPTIONAL – Check this box if a second page is used for additional notes/caregiver names.

10. Check all boxes that apply. If “Rescinding delegation” box is checked, you must complete “Rescinding Delegation

form, DSHS 13-680.

11. and 12. RND Signature and Date: Sign and date your signature.

13. Return Visit On Or Before: Enter a date or the number of days within the 90 day time frame, that you will return for

the next supervisory visit.

14. See number 1. above.

15. See number 2. above.

16. See number 3. above.

17. See number 7. above.

18. See number 8. above.

19. and 20. See number 11. and 12. above.

21. See number 13. above.

Be sure to sign and date both pages if a second page is used.

DSHS 14-484 (REV. 04/2013)

Nurse Delegation: Nursing Visit Page 3