Nursing Plan of Care, SFN 807 525-05-60-52

(NEW 07/01/2024 ML #3847)

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Registered Nurse approved to provide Nurse Education will complete the entirety of the Nursing Plan of Care.

 

Nurse Educator will fill in member name, member ID number, nurse educator, back-up nurse educators name with nurse educator phone numbers, case manager, and case manager phone number.

 

Section 1:

  1. Nurse Educator will fill in all medical diagnoses and pertinent medical history

  2. Nurse Educator will complete physical assessment

    1. Ailments are fillable or drop-down box

    2. Provide comments related to ailments

    3. Nurse may add or delete rows to accommodate the needs of the consumer

  3. Nurse Educator will assess and fill out blood pressure, pulse, pulse type, respirations, temperature, pain assessment, height, weight, diet, supplements, and any additional comments related to physical assessment

  4. Nurse Educator will fill out allergies and sensitivities

  5. Nurse Educator will fill out medication list with name, dose, and times per day

    1. Nurse Educator may add or delete rows to accommodate medication list needs

    2. May provide separate document of medication list

  6. Nurse Educator will fill out the requested nursing tasks, frequency and units needed for each task and if a nurse or non-nurse will be completing the task

    1. Nurse Educator may add or delete rows to accommodate medical task list

    2. Nurse Educator to provide any additional comments related to medical tasks requested

  7. Nurse Educator will fill out number of units estimated per month and six months

    1. Fill out nursing tasks per nurse as the QSP

    2. Fill out nursing tasks per non-nurse as the QSP

  8. Nurse Educator will fill out any additional nurse educator units that are requested for training non-nurse QSPs

  9. Nurse Educator will fill check the box for what type of QSP will be completing the medical task(s): nurse or non-nurse who is trained and verified competent to complete the medical task

    1. Nurse Educator will fill out instructions and steps for approving nursing tasks including:

      1. Contraindications

      2. Risks

      3. Precautions

      4. Reportable Incidents

      5. Contingency Plan in case of emergency

  10. Nurse Educator will fill review Nurse Educator agreement and critical incident reporting requirements

  11. Nurse Educator prints or types name, date, and time of completion of the SFN 807

  12. Nurse Educator signs SFN 807

  13. Print RNs name and license number

    1. If licensed outside of North Dakota in a Nurse Compact state, provide State where the nurse is licensed

  14. If nurse education has not been approved for Virtual Supports Option, the QSP Nurse Educator will stop here and submit document to HCBS Case Manager for State RN Program Administrator review

Section 2:

 

If the Nurse Educator has received approval from the State RN Program Administrator to provide EPCS via Virtual Supports Option, the RN Nurse Educator will continue to fill out Section 2 of the SFN 807.

  1. Nurse Educator will review Virtual Support Option requirements

  2. Nurse Educator will acknowledge completion by checking each box listed below the requirements to confirm understanding

  3. Nurse Educator will fill out which HIPPA compliant service delivery provider was utilized

  4. Nurse Educator will fill out where the Nurse Educator was located during the time the Virtual Supports Option was utilized

  5. Nurse Educator will fill out where the client was located during the time the Virtual Supports Option was utilized

  6. Nurse Educator will complete the number of Nurse Education units requested per month if additional units are needed and the frequency needed

  7. Nurse Educator will total the units for a six-month period

  8. Nurse Educator will write detailed plan on how the Nurse Educator will address any health, safety, or behavioral needs while the Virtual Supports Option is being provided

  9. Nurse Educator will review HIPPA laws and print Nurse Educator name, sign, and date the form

  10. Nurse Educator will submit document to HCBS Case Manager for State RN Program Administrator review