Nurse Delegation Assumption Of Delegation Form printable pdf download

Nurse Delegation Assumption Of Delegation Form

Nurse Delegation: Assumption of Delegation

1. CLIENT NAME

2. DATE OF BIRTH

3. ID/SETTING (OPTIONAL)

4. FACILITY OR PROGRAM NAME (OPTIONAL)

5. TELEPHONE NUMBER

6. REASON/DATES FOR ASSUMING DELEGATION

I agree that I know the client through my assessment, the plan of care, the skills of the nursing assistant, and the delegated task(s). I

agree to assume responsibility and accountability for the delegated task(s) and to perform the nursing supervision. I have informed the

client and/or authorized representative of this change. I have informed the nursing assistant, case manager and client of this change.

7. RND SIGNATURE

8. DATE

DSHS 13-678B (REV. 04/2013)

To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078

DISTRIBUTION: Copy in client chart and in RND file

Instructions for Completing Nurse Delegation: Assumption of Delegation

All fields are required unless indicated “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, day, 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. Facility or Program Name: OPTIONAL – Enter name of facility/program contact.

5. Telephone Number: OPTIONAL – Enter telephone number of facility/program contact including area code.

6. Reason/Dates for Another RND to Assume Delegation: Enter reason other RND rescinded and the date you assume

responsibility for delegation.

7. and 8.

Assuming RND Signature and Date: Sign and date your signature.

DSHS 13-678B (REV. 04/2013)

Nurse Delegation Assumption Of Delegation Form