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

Current through Register Vol. 40, No. 6, March 31, 2022

(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 shall conduct and document focused nursing assessments of the health status of patients by:
(a) 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.
(b) Distinguishing abnormal from normal data.
(c) Recording and reporting the data.
(d) Anticipating and recognizing changes or potential changes in patient status; identifying signs and symptoms of deviation from current health status.
(e) Reporting findings of the focused nursing assessment to the registered nurse, licensed physician, advanced practice nurse, or dentist.
(f) Implementing the plan of care.
(g) Modifying the plan of care following implementation, based upon the evaluation of patient responses to the plan of care, consistent with state and federal regulations.

Notes

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.

Author: Alabama Board of Nursing

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

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