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<br />Control Numbe r: <br />401.06.03.043 <br />Version: <br />3.0 <br />T itle: <br />Nursing Asses s m ent Protoc ols <br />Page Numbe r: <br />4 of 5 <br /> <br />GENERAL REQUIREM ENTS <br /> <br />1. Introduction <br />Nursing asses sment protoc ols are written ins truc tions or guidelines that s pec ify the s teps to <br />be taken in evaluating a patient’s health s tatus and providing intervention. They also aid <br />nurs ing s taff and other specific qualified health care profess ionals in the dispos ition of <br />selected, specific health conditions. Such pr otoc ols m ay inc lude acceptable firs t-aid <br />procedures for the identification and c are of ailments that ordinarily would be treated by an <br />individual with over-the-c ounter medic ation or through self-care. <br /> <br />Nursing asses sment protoc ols may also address m ore serious sym ptoms such as chest <br />pain, shortness of breath, or intoxication. <br /> <br />Nursing asses sment protoc ols fac ilitate the initiation of treatment of identified conditions and <br />ensure appropriate referral. <br /> <br /> <br />2. G uide line s <br /> Each nurs ing asses s ment protocol shall be written in acc ordance with the Idaho <br />Nurse Prac tice Act and m ust spec ify level of s kill and preparation of health care <br />personnel privileged to use the protoc ol. Al l nursing ass es s ment protoc ols shall be <br />forwarded to the health authority, following the annual review at the institution level, <br />for review and approval. <br /> <br /> Nursing asses sment protoc ols will be kept in a m anual in all health c are areas where <br />nurs ing s taff and other qualified health care professionals will provide care in <br />acc ordance with the protoc ols. <br /> <br /> Subjective and objective areas lis ted in the nurs ing ass es s m ent protoc ol s hould be <br />ass essed and appropriate positive/negative findings doc um ented in the progress <br />notes. The asses s ment, plan, and patient educ ation provided are also to be <br />documented in the progress notes according to the nurs ing asses s m ent protocol. <br /> <br /> Each entry is to be rec orded in the subjective, objective, assessm ent, plan (SOAP ) <br />charting format; s igned; dated; and timed. <br /> <br /> If the ass es s ment indicates that orders for treatm ent are to be initiated, these are to <br />be written on the order s heet exactly as outlined in the nurs ing ass es s ment protocol. <br /> <br /> If the deviation from treatm ent listed in the protoc ol is necess ary, the nurse or other <br />qualified health care profess ional m us t obtain an order from the res ponsible <br />physic ian, dentist, nurse prac titioner or phys ician assis tant. <br /> <br /> Multiple applications of the same order on the s ame patient should be reviewed by <br />the physic ian or m id-level provider. <br /> <br /> The health care rec ord of any offender for whom treatment was initiated under a <br />written protoc ol that inc ludes orders for a legend drug or diagnos tic procedure, will <br />be reviewed by a phys ician, dentis t, physic ian as s istant or nurse prac titioner (as <br />approved by the fac ility m edical director) within 72 hours. The phys ician or <br />prac titioner will review and initial the progress note written by the nurse and <br />countersign the order. <br /> <br /> For the purpose of health care rec ord c larity, the review and counter s igning shall be <br />dated and tim ed.