DHS 105.19(4)(a)6. 6. Regularly reevaluating the patient’s needs.

DHS 105.19(4)(b) (b) Nursing services not requiring a registered nurse may be provided by a licensed practical nurse under the supervision of a registered nurse. Licensed practical nurse duties include:

DHS 105.19(4)(b)1. 1. Performing nursing care delegated by an RN under s. N 6.03;

DHS 105.19(4)(b)2. 2. Assisting the patient in learning appropriate self-care techniques; and

DHS 105.19(4)(b)3. 3. Meeting the nursing needs of the recipient according to the written plan of care.

DHS 105.19(4)(c) (c) Both RNs and LPNs shall:

DHS 105.19(4)(c)1. 1. Arrange for or provide health care counseling within the scope of nursing practice to the recipient and recipient’s family in meeting needs related to the recipient’s condition;

DHS 105.19(4)(c)2. 2. Provide coordination of care for the recipient, including ensuring that provision is made for all required hours of care for the recipient;

DHS 105.19(4)(c)3. 3. Accept only those delegated medical acts for which there are written or verbal orders and for which the nurse has appropriate training or experience;

DHS 105.19(4)(c)4. 4. Prepare written clinical notes that document the care provided within 24 hours of providing service and incorporate them into the recipient’s clinical record within 7 days; and

DHS 105.19(4)(c)5. 5. Promptly inform the physician and other personnel participating in the patient’s care of changes in the patient’s condition and needs.

DHS 105.19(5) (5) Patient rights. A nurse shall provide a written statement of the rights of the recipient for whom services are provided to the recipient or guardian or any interested party prior to the provision of services. The recipient or guardian shall acknowledge recipient of the statement in writing. The nurse shall promote and protect the exercise of these rights and keep written documentation of compliance with this subsection. Each recipient receiving care shall have the following rights:

DHS 105.19(5)(a) (a) To be fully informed of all rules and regulations affecting the recipient;

DHS 105.19(5)(b) (b) To be fully informed of all services to be provided by the nurse and of related charges, including any charges for services for which the recipient may be responsible;

DHS 105.19(5)(c) (c) To be fully informed of one’s own health condition, unless medically contraindicated, and to be afforded the opportunity to participate in the planning of services, including referral to a health care institution or other agency;

DHS 105.19(5)(d) (d) To refuse treatment to the extent permitted by law and to be informed of the medical consequences of that refusal;

DHS 105.19(5)(e) (e) To confidential treatment of personal and medical records and to approve or refuse their release to any individual, except in the case of transfer to a health care facility;

DHS 105.19(5)(f) (f) To be taught, and have the family or other persons living with the recipient taught, the treatment required, so that the recipient can, to the extent possible, help himself or herself, and the family or other party designated by the recipient can understand and help the recipient;

DHS 105.19(5)(g) (g) To have one’s property treated with respect; and

DHS 105.19(5)(h) (h) To complain about care that was provided or not provided, and to seek resolution of the complaint without fear of recrimination.

DHS 105.19(6) (6) Universal precautions. A nurse shall have the necessary orientation, education and training in epidemiology, modes of transmission and prevention of HIV and other blood-borne or body fluid-borne infections and shall follow universal blood and body-fluid precautions for each recipient for whom services are provided. The nurse shall employ protective measures recommended by the federal centers for disease control (CDC), including those pertaining to medical equipment and supplies, to minimize the risk of infection from HIV and other blood-borne pathogens.

DHS 105.19 Note Note: A copy of the CDC recommended universal precautions may be obtained from the Division of Quality Assurance, P.O. Box 2969, Madison, Wisconsin 53701.

DHS 105.19(7) (7) Medical record. The nurse shall maintain a medical record for each recipient. The record shall document the nature and scope of all services provided and shall be systematically organized and readily accessible to authorized department personnel. The medical record shall document the recipient’s condition, problems, progress and all services rendered, and shall include:

DHS 105.19(7)(a) (a) Recipient identification information;

DHS 105.19(7)(b) (b) Appropriate hospital information, including discharge information, diagnosis, current patient status and post-discharge plan of care;

DHS 105.19(7)(c) (c) Recipient admission evaluation and assessment;

DHS 105.19(7)(d) (d) All medical orders, including the written plan of care and all interim physician’s orders;

DHS 105.19(7)(e) (e) A consolidated list of medications, including start and stop dates, dosage, route of administration and frequency. This list shall be reviewed and updated for each nursing visit, if necessary;

DHS 105.19(7)(f) (f) Progress notes posted as frequently as necessary to clearly and accurately document the recipient’s status and services provided. In this paragraph, “progress note” means a written notation, dated and signed by a member of the health team providing covered services, that summarizes facts about care furnished and the recipient’s response during a given period of time;