Cal. Code Regs. Tit. 22, § 70213 - Nursing Service Policies and Procedures

(a) Written policies and procedures for patient care shall be developed, maintained and implemented by the nursing service.
(1) Policies and procedures which involve the medical staff shall be reviewed and approved by the medical staff prior to implementation.
(2) Policies and procedures of other departments which contain requirements for the nursing service shall be reviewed and approved by the nursing service prior to implementation.
(3) The nursing service shall review and revise policies and procedures every three years, or more often if necessary.
(4) The hospital administration and the governing body shall review and approve all policies and procedures that relate to the nursing service every three years or more often, if necessary.
(b) Policies and procedures shall be based on current standards of nursing practice and shall be consistent with the nursing process which includes: assessment, nursing diagnosis, planning, intervention, evaluation, and, as circumstances require, patient advocacy.
(c) Policies and procedures which contain competency standards for staff performance in the delivery of patient care shall be established, implemented, and updated as needed for each nursing unit, including standards for the application of restraints. Standards shall include the elements of competency validation for patient care personnel other than registered nurses as set forth in Section 70016, and the elements of competency validation for registered nurses as set forth in Section 70016.1. At least annually, patient care personnel shall receive a written performance evaluation. The evaluation shall include, but is not limited to, measuring individual performance against established competency standards.
(d) Policies and procedures that require consistency and continuity in patient care, incorporating the nursing process and the medical treatment plan, shall be developed and implemented in cooperation with the medical staff.
(e) Policies and procedures shall be developed and implemented which establish mechanisms for rapid deployment of personnel when any labor intensive event occurs which prevents nursing staff from providing attention to all assigned patients, such as multiple admissions or discharges, or an emergency health crisis.


Cal. Code Regs. Tit. 22, § 70213

Note: Authority cited: Sections 100275(a) and 1275, Health and Safety Code. Reference: Section 1276, Health and Safety Code.

1. Amendment of section heading and section, and new Note filed 11-26-96; operative 12-26-96 (Register 96, No. 48).

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