Nurse Delegation: Consent For Delegation Process
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1
2Nurse Delegation:
Consent for Delegation Process
1. CLIENT NAME
2. DATE OF BIRTH
3. ID/SETTING (OPTIONAL)
4. CLIENT ADDRESS
CITY
STATE
ZIP CODE
5. TELEPHONE NUMBER
6. FACILITY OR PROGRAM CONTACT
7. TELEPHONE NUMBER
8. FAX NUMBER
9. E-MAIL ADDRESS
10. SETTING
11. CLIENT DIAGNOSIS
12. ALLERGIES
Certified Community Residential
Program for Developmentally Disabled
Licensed Adult Family Home
Licensed Assisted Living Facilities
Private Home/Other
13. HEALTH CARE PROVIDER
14. TELEPHONE NUMBER
Consent for the Delegation Process
I have been informed that the Registered Nurse Delegator will only delegate to caregivers who are capable and willing to
properly perform the task(s). Nurse delegation will only occur after the caregiver has completed state required training
(WAC 246-841-405(2)(a)) and individualized training from the Registered Nurse Delegator. I further understand that the
following task(s) may never be delegated:
•
Administration of medications by injections (IM, Sub Q, IV) except insulin injections.
ESSHB 2668 (2008) specifically allows delegation of insulin injections.
•
Sterile procedures.
•
Central line maintenance.
•
Acts that require nursing judgment
If verbal consent is obtained, written consent is required within 30 days of verbal consent.
15. CLIENT OR AUTHORIZED REPRESENTATIVE SIGNATURE
16. TELEPHONE NUMBER
17. DATE
18. VERBAL CONSENT OBTAINED FROM
19. RELATIONSHIP TO CLIENT
20. DATE
My signature below indicates that I have assessed this client and found his/her condition to be stable and predictable. I
agree to provide nurse delegation per RCW 18.79 and WAC 246-840-910 through 970.
21. RND NAME - PRINT
22. TELEPHONE NUMBER
23. RND SIGNATURE
24. 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 13-678 PAGE 1 (REV. 05/2016)
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