1.
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Registered nurses accept sole accountability and responsibility for the client-specific orders they give.
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2.
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Registered nurses give client-specific orders for activities that are:
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a.
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Within autonomous scope of practice,
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b.
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Within the nurse’s individual competence,
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c.
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Consistent with any relevant standards, limits, and conditions established by BCCNM,
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d.
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Consistent with organizational policy, procedures, and restrictions.
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3.
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Registered nurses only give client-specific orders when organizational supports, processes, and resources, including policies and procedures, exist that:
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a. |
Outline the accountability and responsibility of the nurse, and
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b.
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Ensure continuity of care for the client including the requirements and procedures for responding to questions about client-specific orders, amending client-specific orders and evaluating client outcomes.
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4.
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Registered nurses carry out assessments and make an appropriate nursing diagnosis[2] to ensure that the client's condition can be improved or resolved by the ordered activity before giving a client-specific order.
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5.
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Registered nurses give client-specific orders that consider the unique characteristics, needs and wishes of the client, contain enough information for the order to be carried out safely and are:
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a.
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Based on evidence,
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b.
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Clear, and complete, and
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c. |
Documented, legible, dated and signed with a unique identifier such as a written signature or an electronically generated identifier.
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6.
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Registered nurses give verbal or telephone client-specific orders only when there are no reasonable[3] alternatives and it is in the best interest of the client. In these situations, registered nurses:
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a.
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Ensure that they have the necessary information to conduct the assessment required to give the client-specific order, which may include gathering information from another health care provider when the nurse is not able to directly observe the client,
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b. |
Ask for the client-specific order to be read back to confirm it is accurate,
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c. |
Follow up to ensure that the client-specific order is documented in the client record.
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7.
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Registered nurses using documents that set out the usual care for a particular client group or client (e.g., pre-printed orders or order sets) make the information client-specific by adding the name of the individual client, making any necessary changes, dating their client-specific orders and signing with their unique identifier.
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8.
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Registered nurses identify the specific document (e.g., a decision support tool), in the client’s record, including the name and the date of publication, when they reference that document in a client-specific order.
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9.
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Registered nurses follow the standards
for Acting within Autonomous Scope of Practice and/or
Giving Client-specific Orders when they change or cancel a client-specific order and are responsible and solely accountable for any changes that they make.
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10.
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Registered nurses communicate and collaborate with the professional who gave the client-specific order, the client and other members of the health care team when changing or cancelling a client specific order.
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11.
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Registered nurses follow legal and ethical obligations regarding consent for the care referred to in their client-specific orders.
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