Registered Nurse Delegation Recording Form - Oregon Department Of Human Services printable pdf download

Registered Nurse Delegation Recording Form - Oregon Department Of Human Services

Registered Nurse Delegation

Seniors and People with Disabilities

Facility Name:

Facility #:_____________________

Staff person completing this form: __________________________________Date: ___________

This form is used to record the number of residents receiving delegated services and the

number of delegated tasks or services being performed in this facility. In the space below, enter

the number of residents who receive delegated services. Then indicate the number of delegated

tasks performed in the facility in each of the categories listed. For example, if resident X receives

insulin injections and CBGs as delegated services, count resident X as one resident, and count

one insulin injection task and one CBG task.

If a task does not fit in one of the categories, list it in the “Other” section. These tasks could

include NG tube feeding, wound care, G-tube feeding, colostomy care, catheter irrigation,

tracheostomy care, suctioning and vent care.

Delegated tasks are not assigned tasks; they must be delegated by an RN in according with

Oregon Administrative Rules.

(Note: The R codes below are for DHS use only.)

How many residents receive delegated services? ___________

R30

Please indicate the number of delegated tasks in each of the categories below.

Injections: Insulin:

R31

Other:

R32

CBGs:

R33

Dressing changes:

R34

Other:

Specify: ________________________________________

R35

______________________________________________________________

R memo

Comments:

__________________________________________________________

____________________________________________________________________

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SDS 0821 4/06

Registered Nurse Delegation Recording Form - Oregon Department Of Human Services