Healthcare RN Packet

HEALTHCARE RN PACKET

This Nursing (RN) Packet documents initial nursing assessment, current clinical information, consent for routine nursing care, acknowledgment of privacy practices, and authorization for release of health information as applicable. The patient or authorized representative must complete all applicable sections and sign where indicated.

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Current Medical Information

Hypertension    Diabetes Mellitus    COPD / Respiratory Disease    Cardiac Disease

Renal Disease    Neurologic Disorder    Other (specify below)

Nursing Assessment / Vitals

Height:    Weight:    BP:

Pulse:    Resp:    Temp:

Nursing Orders and Interventions

The undersigned authorizes nursing staff to perform routine assessments and implement nursing interventions as ordered by the attending provider. Routine nursing care may include medication administration, wound care, IV therapy, catheter care, patient education, and coordination of services.

At risk for falls    Not at risk

Consent for Nursing Care

By signing below, I consent to nursing assessment and provision of routine nursing care as described in this packet. I understand that nursing care may include, but is not limited to, vital signs monitoring, medication administration according to provider orders, wound care, IV therapy, sample collection, and provision of patient education. I understand the risks and benefits of the described nursing interventions and that I may refuse any intervention except where refusal would endanger others or where required by law.

I acknowledge that I have the right to ask questions and that I may withdraw consent at any time by notifying nursing staff, except to the extent that actions have already been taken in reliance on this consent.

Consent for specific interventions (check all that apply):
Medication administration as ordered    IV therapy    Wound care / dressing changes    Catheter care

HIPAA / Privacy Acknowledgment

I acknowledge that I have been informed of my privacy rights with respect to my protected health information and that nursing staff will protect the confidentiality of my health information. I authorize nursing staff to communicate relevant clinical information to other members of my care team and, where necessary for care coordination, to my designated emergency contact or authorized representative.

Authorization to disclose information for care coordination and billing purposes: I authorize disclosure as described above.

Patient Certification

I certify that the information provided on this Nursing Packet is accurate and complete to the best of my knowledge. I understand that omission of relevant medical information may affect my care. I consent to the release and use of my health information as described above for purposes of treatment, payment, and health care operations as necessary for my care.

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