Nurse Delegation: Instructions For Nursing Task
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1
2Nurse Delegation:
Instructions for Nursing Task
1. CLIENT NAME
2. DATE OF BIRTH
3. ID/SETTING (OPTIONAL)
4. DATE TASK DELEGATED
5. DELEGATED TASK AND EXPECTED OUTCOME
Complete 6 and 7 only if medication(s) delegated:
VERIFICATION OF DELEGATED MEDICATION
6. LIST SPECIFIC MEDICATION(S), DOSAGES AND FREQUENCY OF
DATE
MEDICATIONS DELEGATED ON THIS DATE (
CHECK HERE IF
ADDITIONAL FORM ATTACHED.)
NAME / TITLE
METHOD OF VERIFICATION
Check here if additional teaching aide(s) attached.
8. STEPS TO PERFORM THE TASK:
Report Side Effects or Unexpected Outcomes To:
9. RND NAME (PRINT)
10. TELEPHONE NUMBER
11. WHAT TO REPORT TO RND
12. HEALTH CARE PROVIDER NAME
13. TELEPHONE NUMBER
14. WHAT TO REPORT TO HEALTH CARE PROVIDER
EMERGENCY SERVICES, 911
15. WHAT TO REPORT TO 911
16. RND SIGNATURE
17. DATE
Call RND when:
•
•
Medications change
Client is admitted to ER, hospital, or SNF
•
•
New orders received
Client moves
•
•
Client dies
Client condition changes
•
Problem/unable to perform nursing task.
To register concerns or complaints about Nurse Delegation, please call 1-800-562-6078
DISTRIBUTION: Copy in client chart and in RND file
NURSE DELEGATION: INSTRUCTIONS FOR NURSING TASK
DSHS 13-678 Page 2 (REV. 05/2016)
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