Rn Supervision of Lpn - Idaho

This "Rn Supervision of Lpn" is a Idaho-specific form released by the Idaho Department of Health and Welfare on October 1, 2013.

Download the form by clicking the link below, fill it out by hand, and mail it as per the guidelines provided by the department or the applicable legal instructions.

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RN Supervision of LPN
G=Guidance
C=Compliancy
I=Instruction
O=Oversight
F=Follow-up
Patient:
MID#
LPNs Evaluated
____________________
Care Plan:
_____Current plan of care available and reviewed
_____Tasks are within scope of LPN practices identified on plan of care
_____Review of doctor’s orders/new doctor’s orders reflected on plan of care
_____Any changes of new nurse interventions
_____Update of care plan needed
Review of LPN Notes:
_____Documentation present that reflects LPN adhering to plan of care
_____Documentation of skilled services performed safely/any documented incidents
regarding omission of nursing care
_____Nurse assessments documented
_____Notes are legible and meet legal standards
Medications:
_____Review of medication sheets
_____Any medication changes/new orders
_____Evidence that medications are administered as ordered/signed off by LPN
_____Medication errors
_____adverse reactions/LPN’s response
Professionalism:
_____Consistent care and evidence of team nursing
_____Supplies available to nursing staff for patient’s care needs
_____Communication with family occurring at shift change
_____Family satisfied with services
Evaluation of LPN Services:
_____Authorized continued delegation of nursing practices
Instruction/RN Comments:
Signed: _____________________________________ Date:
Supervising RN
RN Supervision of LPN Form V1.0
10/2013 sc
RN Supervision of LPN
G=Guidance
C=Compliancy
I=Instruction
O=Oversight
F=Follow-up
Patient:
MID#
LPNs Evaluated
____________________
Care Plan:
_____Current plan of care available and reviewed
_____Tasks are within scope of LPN practices identified on plan of care
_____Review of doctor’s orders/new doctor’s orders reflected on plan of care
_____Any changes of new nurse interventions
_____Update of care plan needed
Review of LPN Notes:
_____Documentation present that reflects LPN adhering to plan of care
_____Documentation of skilled services performed safely/any documented incidents
regarding omission of nursing care
_____Nurse assessments documented
_____Notes are legible and meet legal standards
Medications:
_____Review of medication sheets
_____Any medication changes/new orders
_____Evidence that medications are administered as ordered/signed off by LPN
_____Medication errors
_____adverse reactions/LPN’s response
Professionalism:
_____Consistent care and evidence of team nursing
_____Supplies available to nursing staff for patient’s care needs
_____Communication with family occurring at shift change
_____Family satisfied with services
Evaluation of LPN Services:
_____Authorized continued delegation of nursing practices
Instruction/RN Comments:
Signed: _____________________________________ Date:
Supervising RN
RN Supervision of LPN Form V1.0
10/2013 sc

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