Ala. Admin. Code r. 610-X-6-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 610-X-6-.09 - Standards For Patient Assessment

(1) Patient assessment shall be provided in accordance with the definitions of professional nursing and practical nursing, as defined in the Alabama Nurse Practice Act, Section 34-21-1.

(2) The registered nurse shall conduct and document comprehensive and focused nursing assessments of the health status of patients by:

(a) Collecting objective and subjective data from observations, physical examinations, interviews, and written records in an accurate and timely manner, as appropriate to the patient's health care needs.

(b) Analysis and reporting of data collected.

(c) Developing a plan of care based upon the patient assessment.

(d) Modifying the plan of care based upon the evaluation of patient responses to the plan of care, including:

1. Anticipating and recognizing changes or potential changes in patient status.

2. Identifying signs and symptoms of deviation from current health status.

3. Implementing changes in interventions.

(3) The licensed practical nurse practicing under the supervision of an RN, APRN, physician, or other authorized health care provider shall deliver and participate in nursing care, to include:

(a) Completing independent or comprehensive patient assessments of the health status of the patient under approved standardized procedures.

(b) Collecting objective and subjective data from observations, nursing examinations, interviews, and written records in an accurate and timely manner, as appropriate to the patient's health care needs.

(c) Distinguishing abnormal from normal data.

(d) Recording and reporting the data.

(e) Anticipating and recognizing changes or potential changes in patient status; identifying signs and symptoms of deviation from current health status.

(f) Reporting findings of the focused nursing assessment to the registered nurse, licensed physician, advanced practice nurse, or dentist.

(g) Participating and contributing to the development, modification, and implementation of a patient centered healthcare plan for unstable, unpredictable, or emergent patients to include the evaluation of patient responses, and identification of patient needs and goals.

(h) The licensed practical nurse may plan the nursing care for a patient whose condition is stable or predictable consistent with state and federal regulations.

Ala. Admin. Code r. 610-X-6-.09

New Rule: Filed March 20, 2003; effective April 24, 2003.

Adopted by Alabama Administrative Monthly Volume XXXIV, Issue No. 10, July 29, 2016, eff. 9/8/2016.

Amended by Alabama Administrative Monthly Volume XXXVII, Issue No. 04, January 31, 2019, eff. 3/8/2019.

Amended by Alabama Administrative Monthly Volume XL, Issue No. 12, September 30, 2022, eff. 11/14/2022.

Author: Alabama Board of Nursing

Statutory Authority:Code of Ala. 1975, § 34-21-1(3)(b), 34-21-2(a)(21), 34-21-2(c)(6).