Nurse Delegation: Change In Medical/treatment Orders (Page 2 of 2) in pdf

Instructions for Completing Nurse Delegation: Change in Medical / Treatment Orders

All fields are required unless indicated “OPTIONAL”.

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

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

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

“In- home”.

Date RND Was Notified: Enter date you were notified of change.

By Whom: List name and title of individual who notified delegating nurse of change/new task or medication.

Change in Orders: Check appropriate box to indicate a change or a new task/medication.

How Was the Change Received: Select the method used by the health care provider to communicate the change.

Effective Date of Change: Enter date the change was ordered by health care provider.

If Verbal was selected in #7 above: Insert the name, title (MD, ARNP, PA) and date the order was verified.

10. Nursing Task/Orders: What was the order, and does it require a new task sheet or a change to the current instructions.

11. This Medication Was: OPTIONAL – Complete 11-20 only if a medication was involved. Indicate whether the medication was

changed or new. Complete all boxes (11-20) for each medication changed or ordered new.

12. Date Ordered: Enter the date this change was ordered.

13. Name of Medication(s): Enter name of medication(s) ordered.

14. Start Date: Enter the date the new/changed medication was first administered.

15. Stop Date: Enter, if applicable, last date to administer this medication.

16. Strength/Dose: Enter strength of medication and dose to be administered.

17. Medication Frequency: Enter how often medication is to be administered.

18. Route: Enter route for medication to be administered. Examples: PO, Supp, Topical, Drops, etc.

19. Not to Exceed: Enter maximum number of doses in a specified time period, if applicable.

20. Reason for Medication: Enter the reason the client takes this medication.

Repeat #11 – 20 for each new or changed medication.

21. - 22. Steps to Perform New Task/Medication: OPTIONAL – Complete 21 & 22 only if using this form for a task sheet.

Enter results expected by providing this task/medication.

23. – 24. RND Name and Telephone Number: Print your name and telephone number including area code.

25. What to Report to RND: Enter symptoms or side effects for all tasks, medications on this sheet to be reported to you.

26. – 27. Health Care Provider Name and Telephone Number: Enter health care provider name and telephone number including area

code.

28. What to Report to Health Care Provider: Enter symptoms or side effects for all tasks, medications on this sheet to report to health

care provider.

29. What to Report to Emergency Services, 9-1-1: Enter symptoms or side effects for all tasks, medications on this sheet to report to

emergency services (911)

30. – 31. Delegate Immediately OR Site Visit Required: Choose only one (#30 OR #31) to indicate whether caregiver(s) may provide

the new task/medication immediately or whether a training visit (on site) is necessary prior to delegation. IN EITHER CASE,

THE DOCUMENTATION IN THE CLIENT FILE MUST REFLEDT WHEN DELEGATION FOR THE NEW

TASK/MEDICATION BEGAN.

32. – 33. RND Signature and Date: Sign and date your signature.

DSHS 13-681 (REV. 04/2013)

Nurse Delegation: Change In Medical/treatment Orders Page 2