Cal. Code Regs. Tit. 22, § 70215 - Planning and Implementing Patient Care

(a) A registered nurse shall directly provide:

(1) Ongoing patient assessments as defined in the Business and Professions Code, section 2725(b)(4). Such assessments shall be performed, and the findings documented in the patient's medical record, for each shift, and upon receipt of the patient when he/she is transferred to another patient care area.

(2) The planning, supervision, implementation, and evaluation of the nursing care provided to each patient. The implementation of nursing care may be delegated by the registered nurse responsible for the patient to other licensed nursing staff, or may be assigned to unlicensed staff, subject to any limitations of their licensure, certification, level of validated competency, and/or regulation.

(3) The assessment, planning, implementation, and evaluation of patient education, including ongoing discharge teaching of each patient. Any assignment of specific patient education tasks to patient care personnel shall be made by the registered nurse responsible for the patient.

(b) The planning and delivery of patient care shall reflect all elements of the nursing process: assessment, nursing diagnosis, planning, intervention, evaluation and, as circumstances require, patient advocacy, and shall be initiated by a registered nurse at the time of admission.

(c) The nursing plan for the patient's care shall be discussed with and developed as a result of coordination with the patient, the patient's family, or other representatives, when appropriate, and staff of other disciplines involved in the care of the patient.

(d) Information related to the patient's initial assessment and reassessments, nursing diagnosis, plan, intervention, evaluation, and patient advocacy shall be permanently recorded in the patient's medical record.

Notes

Cal. Code Regs. Tit. 22, § 70215

Note: Authority cited: Sections 1275 and 131200, Health and Safety Code. Reference: Section 2725(b)(4), Business and Professions Code; and Sections 1276,131050, 131051 and 131052, Health and Safety Code.

1. Repealer and new section, and new Note filed 11-26-96; operative 12-26-96 (Register 96, No. 48).
2. Change without regulatory effect amending subsection (a)(1) and Note filed 1-9-2013 pursuant to section 100, title 1, California Code of Regulations (Register 2013, No. 2).