10A NCAC 13B .3804      PATIENT CARE

(a)  Each patient's need for nursing care related to his or her admission shall be determined by a registered nurse. Patient needs shall be reassessed when warranted by the patient's condition.

(b)  Each patient's nursing care shall be based upon assessed needs and shall be coordinated with the therapies of other disciplines.

(c)  The patient's medical record shall include documentation of:

(1)           the initial assessment and reassessments of patient clinical status;

(2)           patient care needs;

(3)           interventions performed to meet the patient's nursing care needs;

(4)           implementation of physician's orders;

(5)           the nursing care provided; and

(6)           the patient's response to, and the outcomes of, the care provided.

(d)  Each plan of care shall be initiated within 24 hours of admission. The plan of care shall become a part of the clinical record.

(e)  The nursing care plan shall be readily available to all physicians and facility personnel involved with the care of the patient.

History Note:        Authority G.S. 131E-79;

Eff. January 1, 1996;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 22, 2017.