Form NDP13 "Nurse Delegation Program Skills Check List" - Alabama

Form NDP13 or the "Nurse Delegation Program Skills Check List" is a form issued by the Alabama Department of Mental Health.

The form was last revised in July 1, 2018 and is available for digital filing. Download an up-to-date Form NDP13 in PDF-format down below or look it up on the Alabama Department of Mental Health Forms website.

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Download Form NDP13 "Nurse Delegation Program Skills Check List" - Alabama

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NDP 13
July 2018
NURSE DELEGATION PROGRAM SKILLS CHECK LIST
NEW
RENEW
_________________________
Agency Name Here
________________________
Staff Name
Date ________________
(Print)
MAS Nurse ____________________________________ Date _________________
(Print)
The unlicensed staff must, without prompting or error, demonstrate all skills delegated in
accordance with the published guidelines with 100% accuracy to the MAS Nurse.
CRITERIA
MAS
STAFF
COMMENTS
NURSE
INITIALS
INITIALS
& DATE
& DATE
I.
Basic Medication Information and Medical Terminology
(Refer to MAS Nurse Manual)
A. States common medical
abbreviations and meanings
B. Describes common dosage forms of
medications and routes of
administration
C. States the 7 rights
D. Describes what constitutes a
medication error
E. Verbalizes the “3 checks”
F. Describes consumer rights related
to:
 Refusal of meds
 privacy and
 respect
G. Defines a medication allergy and
signs of a possible allergic reaction
H. States name and location of
medication references available in the
facility
1
NDP 13
July 2018
NURSE DELEGATION PROGRAM SKILLS CHECK LIST
NEW
RENEW
_________________________
Agency Name Here
________________________
Staff Name
Date ________________
(Print)
MAS Nurse ____________________________________ Date _________________
(Print)
The unlicensed staff must, without prompting or error, demonstrate all skills delegated in
accordance with the published guidelines with 100% accuracy to the MAS Nurse.
CRITERIA
MAS
STAFF
COMMENTS
NURSE
INITIALS
INITIALS
& DATE
& DATE
I.
Basic Medication Information and Medical Terminology
(Refer to MAS Nurse Manual)
A. States common medical
abbreviations and meanings
B. Describes common dosage forms of
medications and routes of
administration
C. States the 7 rights
D. Describes what constitutes a
medication error
E. Verbalizes the “3 checks”
F. Describes consumer rights related
to:
 Refusal of meds
 privacy and
 respect
G. Defines a medication allergy and
signs of a possible allergic reaction
H. States name and location of
medication references available in the
facility
1
NDP 13
July 2018
CRITERIA
MAS
STAFF
COMMENTS
NURSE
INITIALS
INITIALS
& DATE
& DATE
II. Demonstrated appropriate technique to obtain and record the following:
(Refer to MAS Nurse Manual)
A. Blood Pressure
B. Temperature
C. Pulse
D. Respiration
E. Finger stick blood sugar
F. Wong Baker Faces Pain Rating
Scale
G. Changes in functional ability
III.
Administration of Medications
(Refer to MAS Nurse Manual)
A. Verifies use of appropriate
medication delivery system with
pharmacy or factory label
B. States proper medication storage
guidelines
C. Washes hands appropriately
D. Locates a clean and private area
E. Gathers equipment needed
F. Identifies correct person and brings
to medication area
G. Unlocks medication storage area
H. Reads MAR and compares with
label on medication container; checks
expiration date of med; 7 rights
I. Checks allergies
J. Double checks the med label with
the MAR using 7 rights
K. Performs third check of medication
label with the MAR
L. Performs task satisfactorily
M. Verifies medication was
taken/administered
N. Returns medication to proper
storage
O. Documents appropriately on MAR
P. Washes hands appropriately
2
NDP 13
July 2018
CRITERIA
MAS
STAFF
COMMENTS
NURSE
INITIALS
INITIALS
& DATE
& DATE
IV. COMPETENCY VERIFICATION OF ASSISTANCE WITH MEDICATIONS
A. Assistance with medications – Check the type(s) of medications for which
demonstrated competency is validated by the MAS Nurse
. oral – pills/tablets/capsules
. oral – liquid
. oral – buccal/sublingual
. eye – drops
. eye – ointments
. eye – patches
ear – drops
ear – topical (creams/lotions)
hearing aids
nose – drops
nose – sprays/inhalers
topical – creams/ointments/paste
topical – lotions/suspensions
topical – sprays/powders
topical – patches
topical – shampoo
respiratory inhalers
rectal medication
(Suppositories/Enema/Gels)
□ Other:
vaginal medication
(Suppositories/Enema/Gels)
□ Other:
V.
OTHER NURSING TASK VALIDATED
Naloxone Auto Injector
Nebulizer
CPAP
Oxygen concentrator/cannula/mask
Epi-pen
Vagal Nerve Stimulator Wand
Hospital Bed
Mechanical Lift
Weight Scales
3
NDP 13
July 2018
CRITERIA
MAS
STAFF
COMMENTS
NURSE
INITIALS
INITIALS
& DATE
& DATE
VI
APPROPRIATE DOCUMENTATION VALIDATED
MAR
After Assisting with meds
Refused Meds
PRN meds
Missed dose other med error
Meds Held
Self Administration
OTHER REQUIRED DOCUMENTATION
Seizure Record
Treatment Record
Narcotic Count Sheet
Health Care Practitioner Sheet
Medication Error Report Form
Incident Report Form
MAC Call Log/Any other Agency
Required Form
VII.
OTHER SKILLS VALIDATED
Infection Control
First Aid/ Emergency Management
Seizure Management
MAS-MAC Connection
Med/Med Room Security
On-Site Observation
Skills Lab Observation
4
NDP 13
July 2018
SKILLS CHECKLIST SIGNATURE PAGE
ALL MAC TRAINING MUST BE DOCUMENTED ON THE MAC
WORKER TRAINING RECORD
DATE MAC II COMPLETED ___________________________
Every MAC Worker must have a minimum of 8 hours of MAC II Training
Documented in the MAC File [ABN 610-X-7-.06(5)(a)(2)]
(Check one of the boxes below)
Initial MAC II Training
MAC UPDATE Training
Other
________________________________________________
(Explain)
_____________________________________________________________
MAC Worker SIGNATURE ______________________________________
MAC Worker Initials __________
DATE __________________
MAS Nurse
SIGNATURE_____________________________________________
MAS Nurse Initials __________
DATE _______________
ONGOING MAC WORKER TRAINING
Date
Skills
Amount of
MAC Worker
MAS Nurse Signature
Verification
Time
Initials
□ Initial
□ UPDATE
□ Other
(Explain)
□ Initial
□ UPDATE
□ Other
(Explain)
□ Initial
□ UPDATE
□ Other
(Explain)
□ Initial
□ UPDATE
□ Other
(Explain)
5
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