Healthcare CNL Range

HEALTHCARE CNL RANGE

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History

CNL Range Assessment and Orders

Purpose: The Clinical Nurse Leader (CNL) is authorized by the patient to monitor clinical parameters, implement approved nursing interventions, and adjust routine orders within the defined parameter ranges below. The CNL will consult the supervising clinician for values outside these limits or when clinical judgement indicates escalation.

Blood Pressure Range: Systolic to mmHg; Diastolic to mmHg.

Heart Rate Range: to bpm.

Respiratory Rate Range: to breaths per minute.

Temperature Range: to °F.

Oxygen Saturation Minimum: %.

Pain Scale Allowed Range: to (0 = no pain, 10 = worst).

Mobility Level: Independent Assistance required Dependent

Fall Risk: Low Moderate High

Authorized Interventions

Within the ranges specified above, the Clinical Nurse Leader is authorized to initiate or adjust the following routine nursing interventions. Any action taken will be documented in the medical record with time, assessment, and rationale. Interventions that alter standing medication orders, require invasive procedures, or meet exclusion criteria below will require direct clinician authorization.

Adjust non-opiate PRN medication per standing protocols

Initiate or adjust maintenance IV fluids per orders

Order routine laboratory tests within scope for trend monitoring

Request non-emergent imaging studies per protocol

Arrange transfer to higher level of care when escalation criteria met

Exclusion Criteria (interventions not authorized under this document): invasive surgical procedures, initiation of controlled substances beyond existing orders, experimental therapies, and any intervention expressly prohibited by the supervising clinician. Any deviation from protocol requires immediate notification of the supervising clinician and documentation of reason for deviation.

Legal Authorization and Acknowledgment

Authorization: I hereby authorize the Clinical Nurse Leader and designated nursing staff to monitor my condition, implement the authorized interventions listed above, and adjust routine care measures within the specified clinical ranges. I understand that the CNL will document all assessments and interventions in my medical record and will consult the supervising clinician for values or conditions outside the stated ranges or when clinically indicated.

Risks and Benefits: I acknowledge that potential benefits include timely adjustments to my care and prevention of clinical deterioration. Risks may include adverse reaction to medications, need for additional procedures, or transfer to a higher level of care. I have had an opportunity to ask questions and have received responses to my satisfaction.

Right to Withdraw: I understand that I may withdraw this authorization at any time by providing a written revocation to the facility. Withdrawal will not affect actions already taken in reliance on this authorization prior to receipt of the revocation.

HIPAA Acknowledgment: I acknowledge receipt of the facility's privacy practices and consent to the use and disclosure of my health information as necessary for treatment, payment, and health care operations as permitted by law.

Additional Notes / Special Instructions

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