Md. Code Regs. 10.27.09.02

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.27.09.02 - Standards of Care

A. Assessment.

(1) The RN shall collect client health data.

(2) Measurement Criteria.

(a) Data collection shall involve the client, family, significant others, other members of the health care team, and the health record, when appropriate.

(b) Data may include the following dimensions:

(i) Physical;

(ii) Psychological;

(iii) Sociocultural;

(iv) Spiritual;

(v) Cognitive;

(vi) Functional abilities;

(vii) Developmental;

(viii) Economic;

(ix) Technology; and

(x) Life-style.

(3) Priority of data collection is determined by the client's immediate condition or needs, health status, and setting.

(4) Pertinent data shall be collected using appropriate assessment techniques.

(5) Data collection shall include a technology assessment.

(6) The data collection process shall be comprehensive, systematic, and ongoing.

(7) Relevant health status data, including changes, shall be documented in an authorized record which is accessible and in a retrievable form.

B. Analysis and Nursing Diagnosis.

(1) The RN shall analyze the assessment data in determining nursing diagnoses.

(2) Measurement Criteria.

(a) The RN shall analyze the data, consider the options, including technology, and make a determination as to whether the selected options are appropriate for the needs of the client.

(b) Nursing diagnoses shall be:

(i) Derived in a complete, systematic, and ongoing manner from the assessment data;

(ii) Validated with the client, family, significant others, and other members of the health care team, when possible; and

(iii) Documented in a manner that facilitates the determination of expected outcomes and plan of care.

(c) Nursing diagnoses shall identify the nature and extent of the client's health status, capabilities, and limitations.

C. Outcome Identification.

(1) The RN shall identify expected outcomes individualized to the client.

(2) Measurement Criteria.

(a) Outcomes shall be:

(i) Derived in a comprehensive, systematic, and ongoing manner from the diagnoses;

(ii) Directed toward management of the client's health problems;

(iii) Formulated with the client, family, significant other, or other members of the health care team, when possible and appropriate;

(iv) Culturally appropriate and realistic in relation to the client's present and potential capabilities;

(v) Attainable in relation to the resources available to the client;

(vi) Documented as measurable goals with time estimates for attainment as appropriate; and

(vii) Documented in an authorized record which is accessible and in a retrievable form.

(b) Outcomes provide direction for continuity of care.

D. Planning.

(1) The RN shall develop a plan of care that prescribes interventions to attain expected outcomes.

(2) Measurement Criteria.

(a) The plan shall be:

(i) Individualized in a comprehensive, systematic and ongoing manner;

(ii) Developed utilizing available data;

(iii) Prioritized to meet the client's condition or needs;

(iv) Developed, coordinated, and communicated with the client, family, significant other, and other members of the health care team as appropriate;

(v) Congruent with the client's therapeutic regime; and

(vi) Documented.

(b) The plan shall:

(i) Reflect current nursing practice;

(ii) Provide for continuity of care; and

(iii) Include identification, coordination, and utilization of available resources.

E. Implementation.

(1) The RN shall implement the interventions identified in the plan of care.

(2) Measurement Criteria.

(a) Interventions shall be:

(i) Implemented recognizing the rights of the client, the family, and significant others;

(ii) Consistent with the established plan of care;

(iii) Implemented in a competent, safe, and appropriate manner consistent with knowledge of scientific principles; and

(iv) Documented.

(b) Interventions may include, but are not limited to:

(i) Patient teaching;

(ii) Counseling;

(iii) Implementing clinical practice guidelines, protocols, and pathways; and

(iv) Independent nursing functions.

(c) Selected interventions may be assigned and delegated to other personnel participating in delivering care.

(d) When assignment or delegation occurs, supervision is provided.

(e) A safe and therapeutic environment is provided for the delivery of nursing care.

(f) Relevant information which may be needed to carry out the nursing plan is provided to the client, family, significant others, and other members of the health care team without violating the client's confidentiality.

F. Evaluation.

(1) The RN shall evaluate the client's progress toward attainment of outcomes.

(2) Measurement Criteria.

(a) Evaluation shall be systematic, ongoing, and criterion-based.

(b) The client, family, significant other, and other members of the health care team shall be involved in the evaluation process, when appropriate.

(c) Ongoing assessment data shall be used to evaluate the process of care and to revise the nursing diagnosis, outcomes, and the plan of care.

(d) Revisions of diagnoses, outcomes, and the plan of care shall be documented.

(e) The effectiveness of interventions shall be evaluated in relation to outcomes.

(f) The responses to interventions shall be documented and communicated to the client and other members of the health care team.

(g) The RN charged with the documentation of the client's discharge shall make the final nursing evaluation.

Md. Code Regs. 10.27.09.02

Regulations .02 adopted effective April 3, 2000 (27:6 Md. R. 642)