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(1) The registered nurse shall conduct and document nursing assessments of the health status of individuals and groups by:

(a) collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner. The data includes, but is not limited to:

(i) biophysical, emotional, and mental status;

(ii) growth and development;

(iii) cultural, spiritual, and socio-economic background;

(iv) family health history;

(v) information collected by other health team members;

(vi) client knowledge and perception about health status and potential, or maintaining health status;

(vii) ability to perform activities of daily living;

(viii) patterns of coping and interacting;

(ix) consideration of client's health goals;

(x) environmental factors (e.g., physical, social, emotional, and ecological) ; and

(xi) available and accessible human and material resources;

(b) sorting, selecting, reporting, and recording the data;

(c) validating, refining, and modifying the data by utilizing available resources, including interactions with the client, family, significant others, and health team members.

(2) The registered nurse shall establish and document nursing analysis which serves as the basis for the strategy of care.

(3) The registered nurse shall develop the strategy of care based upon data gathered in the assessment and conclusions drawn in the nursing analysis. This includes:

(a) identifying priorities in the strategy of care;

(b) collaboration with the client to set realistic and measurable goals to implement the strategy of care;

(c) prescribing nursing intervention(s) based on the nursing analysis; and

(d) identifying measures to maintain comfort, to support human functions and positive responses, and to maintain an environment conducive to teaching to include appropriate usage of health care facilities.

(4) The registered nurse shall implement the strategy of care by:

(a) initiating nursing interventions through:

(i) giving direct care;

(ii) assisting with care;

(iii) assigning and delegating care; and

(iv) collaborating and/or referring when appropriate;

(b) providing an environment conducive to safety and health;

(c) documenting nursing interventions and responses to care to other members of the health team; and

(d) communicating nursing interventions and responses to care to other members of the health team.

(5) The registered nurse shall evaluate the responses of individuals or groups to nursing interventions. Evaluation shall involve the client, family, significant others, and health team members.

(a) Evaluation data shall be documented and communicated to appropriate members of the health team.

(b) Evaluation data shall be used as a basis for reassessing client health status, modifying nursing analysis, revising strategies of care, and prescribing changes in nursing interventions.

(c) Research data shall be utilized in nursing practice.

History: 37-1-131, 37-8-202, MCA; IMP, 37-1-131, 37-8-202, MCA; NEW, 1985 MAR p. 1556, Eff. 10/18/85; AMD, 1997 MAR p. 626, Eff. 4/8/97; TRANS, from Commerce, & AMD, 2006 MAR p. 2035, Eff. 8/25/06.

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