Nurse Delegation: Change In Medical/treatment Orders

ADVERTISEMENT

Nurse Delegation:
Change in Medical / Treatment Orders
1. CLIENT NAME
2. DATE OF BIRTH
3. ID /SETTING (OPTIONAL)
4. DATE RND WAS NOTIFIED
5. BY WHOM
6. CHANGES IN ORDER(S)
New med.
Change in a delegated med
New nursing task
Change in a nursing task
7. HOW WAS THE CHANGE RECEIVED?
8. EFFECTIVE DATE OF CHANGE
Written
Faxed
Verbal
9. Only Complete if number 7 was a verbal order.
NAMEOF PERSON PROVIDING VERIFICATION
TITLE OF PERSON PROVIDING VERIFICATION
DATE OF VERIFICATION
New task(s) sheet required
Current task(s) sheets(s) updated
No change to task(s) sheet(s)
10. NURSING TASK(S)
NURSING TASK / ORDER
11. This medication(s) was:
New
Changed
12. DATE ORDERED
13. NAME OF MEDICATION(S)
14. START DATE
15. STOP DATE (IF APPLICABLE)
16. STRENGTH/DOSE
17. MEDICATION FREQUENCY
18. ROUTE
19. NOT TO EXCEED
20. REASON FOR MEDICATION(S)
11. This medication(s) was:
New
Changed
12. DATE ORDERED
13. NAME OF MEDICATION(S)
14. START DATE
15. STOP DATE (IF APPLICABLE)
16. STRENGTH/DOSE
17. MEDICATION FREQUENCY
18. ROUTE
19. NOT TO EXCEED
20. REASON FOR MEDICATION(S)
Optional Task Sheet: (21 – 29)
21. STEPS TO PERFORM THE NEW TASK(S)
22. EXPECTED OUTCOME OF DELEGATED TASK(S)
Report side effects or unexpected outcomes to::
23. RND NAME (PRINT)
24. TELEPHONE NUMBER
25. WHAT TO REPORT TO RND
26. HEALTH CARE PROVIDER
27. TELEPHONE NUMBER
28. WHAT TO REPORT TO HEALTH CARE PROVIDER
29. WHAT TO REPORT TO EMERGENCY SERVICES, 911
Select Only One of the Following
30.
Delegate immediately. No site visit required. The above order and instructions have been communicated to the delegated
caregiver(s) and this form should be added to the client’s chart. OR
31.
A site visit required for training or assessment prior to delegation. The caregiver may not perform the task until the site visit is
completed.
32. RND SIGNATURE
33. DATE
To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078
DISTRIBUTION: Copy in client chart and in RND file
DSHS 13-681 (REV. 04/2013)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2