Form Dshs 13 680 – Fill Out and Use This PDF

Nurse Delegation: Rescinding Delegation

1. CLIENT NAME

2. DATE OF BIRTH

3. ID/SETTING (OPTIONAL)

4. FACILITY OR PROGRAM NAME (OPTIONAL)

5. TELEPHONE NUMBER

6. Reason for Rescinding: (Check all that apply)

A. Client died

F. NA not competent

K. Rescinding facility

B. Client’s condition changed

G. NA not willing

including clients and nurse assistant

C. Frequent staff turnover

H. NA credential expired

L. Other (specify)

D. Client/authorized

I. NA No longer working with

representative requested

client

E. Task not performed correctly

J. Client safety compromised

7. TASK RESCINDED

10. MEDICATIONS

11.

9. ALL

BLOOD

8. NAMES OF CAREGIVERS

TASKS

ORAL

TOPICAL

DROPS

SUGAR

12. OTHER/SPECIFY

1)

2)

3)

4)

5)

6)

7)

8)

9)

10)

13.

Case Manager Notified (When

14. NAME OF CASE MANAGER NOTIFIED

15. DATE

appropriate)

16. ALTERNATIVE PLAN FOR CONTINUING THE TASK

17. RND SIGNATURE

18. 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 13-680 (REV. 04/2013)

Instructions for Completing Nurse Delegation: Rescinding 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”,

DDDProgram, “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 for Rescinding: Mark the boxes next to the reason for rescinding. Mark all that apply.

7.Task Rescinded: Enter name of task rescinded. If medication, list name. This applies to all caregivers delegated for this task.

8.Names of Caregivers: Enter name of individual caregiver rescinded. If all, enter “ALL”.

9.All Tasks: Enter “X” under all tasks next to name of appropriate caregiver(s).

10.Medications: Enter name of individual medication if appropriate. If all, enter “ALL”.

11.Blood Sugar: Enter “X” if blood sugar rescinded.

12.Other/Specify: OPTIONAL – List other tasks rescinded or list date if appropriate.

13.OPTIONAL – Check the box if appropriate. Case Manager must be notified if ALL tasks (client condition has changed) are rescinded or ALL caregivers (client unable to receive needed services).

14.Name of Case Manager Notified: Enter case manager name, if notified.

15.Date: Enter date the case manager was notified.

16.Alternative Plan for Continuing the Task: Describe how client’s needs will continue to be met.

17.and 18. RND Signature and Date: Sign and date your signature. The date the form is signed is the date of rescinding, unless otherwise noted in #7.

DSHS 13-680 (REV. 04/2013)