Leal Responsibilities: Documenting Admission Data

1. All clients should be asked whether they have advance directives upon admission to a health

care facility.

2. Staff should give clients who do not have advance directives written information that outlines

their rights related to health care decisions and how to formulate advance directives.

3. The purpose of advance directives is to communicate a client’s wishes regarding end-of-life care

should the client become unable to do so.

Professional Responsibilities: Admission Requirements from the

Patient Self-Determination Act

1. Professional responsibilities are the obligations that nurses have to their clients. To meet their

professional responsibilities, nurses must be knowledgeable in the following area: client rights,

advocacy, informed consent, advance directives, information technology, legal practice,

disruptive behavior, and ethical practice.

2. The Patient Self-Determination Act stipulates that on admission to a health care facility, all

clients must be informed of their right to accept or refuse care. Competent adults have the right

to refuse treatment, including the right to leave a health care facility without a prescription for

discharge from the provider.

3. If the client refuses a treatment or procedure, the client is asked to sign a document indicating

that they understand the risk involved with refusing the treatment or procedure, and that they

have chosen to refuse it.

Managing Client Care: Evaluating an Assistive Personnel’s

Performance

1. Examples of tasks that nurses can delegate to assistive personnel are: activities of daily living

(ADLs), bathing, grooming, dressing, toileting, ambulating, feeding (without swallowing

precautions), positioning, routine tasks, bed making, specimen collection, intake and output,

and vital signs (for stable clients).

2. A licensed nurse is responsible for providing clear directions when a task is initially delegated

and for periodic reassessment and evaluation of the outcome of the task.

3. The nurse should use judgment and knowledge related to the scope of practice and the

delegatee’s skill level when delegating.