NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
1. General delegation rules to follow for the RN:: -Always be familiar with your state board rules
and regulations for delegation.
-Refer to you facility policies and procedures for roles and responsibilities for task delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN and/or UAP) have the training and skill set
to complete the task delegated to them.
-Always validate! If you are unsure if a staff member does not have the knowledge or skills to complete a task, ask them
to demonstrate by stating "Please show me how you would do this".
2. UAP Delegation:: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains, etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give medication.
3. LVN/LPN Delegations:: -Dressing changes.
-Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
4. As the RN you MUST complete the following items, they cannot be delegat-
ed:: -Assessments/ reassessments.
-Evaluation (think nursing process).
-Education/teaching.
-Transfers (on or off the unit-they will need an assessment).
-Post mortem care.
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post op assessment).
5. Things to remember as an RN delegating:: -Always remember, as an RN, you will also be
delegated too- this means the first step when a patient assignment or task is delegated to YOU is to figure out what is
needed or required.
1/7
, NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
-If there are patients/tasks you do not have the knowledge or skill set to care for or complete, report to your charge
nurse.
6. Documentation must be:: -Timely.
-Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
7. Documentation Standards:: -You can't look up a patient that you had the day before (HIPAA violation).
-If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
8. Rules and Regulations with Documentation:: -Ethical and Legal Concerns.
-Confidentiality of all patient information.
-HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
9. Source-oriented:: Each profession has a separate section of the record in which to do narrative charting.
10. Problem-oriented medical record (POMR):: Integrates charting from the entire care team in
the same section of the record.
11. Nurse's notes may be in a narrative format or in a problem-oriented struc-
ture, such as...: PIE, APIE, SOAP, SOAPIE, SOAPIER, or CBE format.
12. Charting by exception:: -Agencies develop standards of nursing practice.
-Documentation according to standards involves a check mark.
-Exceptions to standards described in narrative form on nurses' notes. Only chart what is significant or abnormal.
13. Flow sheets:: -Graphic record.
-Intake and output, vital signs, and blood glucose.
-Medication administration record.
-Skin assessment record, daily weights.
-Used when a comparison is required or helpful.
14. Documentation DO'S:: -Chart a change in client's condition and that follow up actions were taken.
-Read the nurses' notes prior to care.
2/7
Study online at https://quizlet.com/_c3pv2h
1. General delegation rules to follow for the RN:: -Always be familiar with your state board rules
and regulations for delegation.
-Refer to you facility policies and procedures for roles and responsibilities for task delegation.
-NEVER assume! Always ensure those you are delegating to (RN, LVN/LPN and/or UAP) have the training and skill set
to complete the task delegated to them.
-Always validate! If you are unsure if a staff member does not have the knowledge or skills to complete a task, ask them
to demonstrate by stating "Please show me how you would do this".
2. UAP Delegation:: -Setting bed alarms, VS.
-Check patient status as directed by the RN- must report findings to the RN ("are you still having pain?").
-Emptying drainage devices (indwelling urinary cats, suprapubic caths, JP drains, etc).
-Record meals/routines.
-Typically UAPs do not care for chest tubes (even drainage). UAPs cannot give medication.
3. LVN/LPN Delegations:: -Dressing changes.
-Apply O2.
-Give PO, IM, SQ medications.
-Enemas.
-Urinary catheter insertion.
-Can care for stable patients that are not complex.
-No IVs or IV medications.
4. As the RN you MUST complete the following items, they cannot be delegat-
ed:: -Assessments/ reassessments.
-Evaluation (think nursing process).
-Education/teaching.
-Transfers (on or off the unit-they will need an assessment).
-Post mortem care.
-Abnormal results.
-Plan of care development.
-Going to or coming from surgery (includes pre op check lists and initial post op assessment).
5. Things to remember as an RN delegating:: -Always remember, as an RN, you will also be
delegated too- this means the first step when a patient assignment or task is delegated to YOU is to figure out what is
needed or required.
1/7
, NSG 3130 Exam 1
Study online at https://quizlet.com/_c3pv2h
-If there are patients/tasks you do not have the knowledge or skill set to care for or complete, report to your charge
nurse.
6. Documentation must be:: -Timely.
-Accurate.
-Complete.
-Factual.
-NO slang or bias language-factual and objective.
-ALL CHARTING IS CONSIDERED LEGAL DOCUMENTATION.
7. Documentation Standards:: -You can't look up a patient that you had the day before (HIPAA violation).
-If you are the interviewing nurse, you can access client's chart.
-You can document meds on the patient you gave meds to: do not document medications or tasks you did not complete.
-Only need a section witness on required meds.
-You can discuss care of a client with the nurse that is precepting you.
8. Rules and Regulations with Documentation:: -Ethical and Legal Concerns.
-Confidentiality of all patient information.
-HIPAA updated April 14, 2003.
-Ensuring confidentiality of computer records.
9. Source-oriented:: Each profession has a separate section of the record in which to do narrative charting.
10. Problem-oriented medical record (POMR):: Integrates charting from the entire care team in
the same section of the record.
11. Nurse's notes may be in a narrative format or in a problem-oriented struc-
ture, such as...: PIE, APIE, SOAP, SOAPIE, SOAPIER, or CBE format.
12. Charting by exception:: -Agencies develop standards of nursing practice.
-Documentation according to standards involves a check mark.
-Exceptions to standards described in narrative form on nurses' notes. Only chart what is significant or abnormal.
13. Flow sheets:: -Graphic record.
-Intake and output, vital signs, and blood glucose.
-Medication administration record.
-Skin assessment record, daily weights.
-Used when a comparison is required or helpful.
14. Documentation DO'S:: -Chart a change in client's condition and that follow up actions were taken.
-Read the nurses' notes prior to care.
2/7
