N.J. Admin. Code § 8:43G-18.5

Current through Register Vol. 56, No. 23, December 2, 2024

Section 8:43G-18.5 - Nursing care patient services

(a) Registered professional nurses and licensed practical nurses shall provide patient care commensurate with their scope of practice, as delineated in the Nurse Practice Act.

1. Patient care may be provided by certified nurse practitioners/clinical nurse specialists in accordance with New Jersey State Board of Nursing rules at N.J.A.C. 13:37-7.

2. Nursing students shall render care to patients only when qualified supervision, as defined by the hospital and the nursing school, is available in the unit.

(b) All patients shall be under the supervised care of a registered professional nurse at all times.

(c) The nursing plan of care shall be consistent with the medical plan of care and implemented in accordance with the Nurse Practice Act.

(d) A registered professional nurse shall perform an initial assessment of the patient and identify patient problems for each patient upon admission. A completed assessment note, which addresses patient problems, identifies expected patient outcomes, and includes anticipated discharge needs, shall be prepared by a registered professional nurse within 24 hours of admission. The patient's anticipated discharge requirements shall be communicated as needed to the professional responsible for discharge planning or case coordination in accordance with facility policy.

(e) Each patient shall receive nursing care that is organized around ongoing, patient-specific care planning and is consistent with medical care planning. The planning shall include setting measurable goals with the patient and family to the extent possible. This planning, nursing interventions, and patient responses shall be documented in the medical record as defined by hospital policy.

(f) The patient's or family's educational needs shall be met throughout the hospital stay, unless they are not capable of receiving education, and shall include at least:

1. Orientation to the patient's environment;

2. How and when to communicate with the staff;

3. Information about the patient's medications and their administration;

4. The patient's activity limitations and professional expectations of his or her activity level;

5. The patient diet; and

6. Information about the extent of self-care that can be rendered during the hospital stay and after discharge.

(g) There shall be a system for receiving, evaluating, and addressing patient and family concerns related to nursing care.

(h) All nursing staff shall wear easily readable name tags that include their name and status, such as RN, LPN, unit clerk, or nurse assistant. The hospital shall have a policy to identify nursing unit exceptions to this procedure where necessary.

(i) Patient discharge instructions shall be documented in the patient's medical record at the time of discharge.

(j) Allergies shall be listed on the front cover of the patient's chart or, in a computerized system, highlighted on the screen.

(k) Patients who require assistance in feeding shall be identified, and there shall be a mechanism in place to assure that assistance is provided.

N.J. Admin. Code § 8:43G-18.5

Amended by R.1992 d.72, effective 2/18/1992.
See: 23 New Jersey Register 2590(a), 24 New Jersey Register 590(a).
Stylistic change.
Amended by R.1995 d.124, effective 3/20/1995.
See: 26 New Jersey Register 4537(a), 27 New Jersey Register 1290(a).
Amended by R.1999 d.436, effective 12/20/1999.
See: 31 New Jersey Register 367(a), 31 New Jersey Register 614(a), 31 New Jersey Register 4293(c).
Rewrote (d).