Nurse Delegation: Consent For Delegation Process (Page 2 of 2) in pdf

Instructions for Completing Nurse Delegation: Consent for Delegation Process

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”,

DDD Program, “In-home”.

4. Client Address: Enter the address where the client currently resides, including street address, city, state and zip

code.

5. Telephone Number: Enter the telephone including area code where the client can be reached.

6. Facility or Program Contact: Enter the name of facility or name of individual to contact at the facility. Enter N/A if

client resides in own home.

7. Telephone Number: Enter the telephone number including area code if different from 5. above.

8. Fax Number: Enter the fax number at the facility if available.

9. E-mail Address: Enter e-mail address of client or facility if available.

10. Setting: Check the appropriate box.

11. Client Diagnosis: Enter client’s diagnoses that affect the delegated task.

12. Allergies: List known allergies or “N/A” if none.

13. Health Care Provider: Enter name of client’s health care provider.

14. Telephone Number: Enter telephone number including area code of provider named in 13.

15. Client or Authorized Representative Signature: Read the statement to the client/authorized representative and

explain the nurse delegation process to them before they sign.

16. Telephone Number: Ask them to enter their telephone number if different from 5. above.

17. Date: Date the signature.

18. Verbal Consent Obtained From: Read the statement to the client/authorized representative and explain the nurse

delegation process to them before obtaining verbal consent. Print the name. Written consent must be obtained within

30 days of verbal consent.

19. Relationship to Client: Enter the relationship of the person to the client named in 18. above.

20. Date: Date when you obtained verbal consent.

21. PND Name: Print your name.

22. Telephone Number: Enter your telephone number including area code.

23. and 24. RND Signature and Date: Sign and date your signature verifying consent.

DSHS 13-678 PAGE 1 (REV. 05/2016)

Nurse Delegation: Consent For Delegation Process Page 2