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Form 1572 Nursing Task Screening Tool

The Nursing Tasks Screening Tool is designed to assess whether a program participant requires assistance from paid staff for various medical and daily living tasks. It includes sections on physician delegation, medication administration, and specific needs related to eating, bathing, toileting, and mobility. The program provider must review the responses and determine if an RN nursing assessment is necessary for the individual's health and safety.

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16 views2 pages

Form 1572 Nursing Task Screening Tool

The Nursing Tasks Screening Tool is designed to assess whether a program participant requires assistance from paid staff for various medical and daily living tasks. It includes sections on physician delegation, medication administration, and specific needs related to eating, bathing, toileting, and mobility. The program provider must review the responses and determine if an RN nursing assessment is necessary for the individual's health and safety.

Uploaded by

leara.brown39
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Form 1572

May 2019-E

Nursing Tasks Screening Tool


Name of Program Participant Date

A. Physician Delegation (see form instructions for definition of physician delegation)


Has a physician delegated all medical acts that will be completed by unlicensed staff?

Yes No If “Yes,” skip to Section C.

B. Medication Administration
Does the individual require administration of medication by a paid staff to ensure that medications are received safely?

Yes No

Includes the following routes of administration:


Oral Topical Nasal Metered dose inhaler (by mouth)

Eye or ear drops Injections (including insulin) Sublingual (under the tongue) Suppositories (rectal or vaginal)
Intravenous/IV Nebulizer Enteral tube/naso-gastric (NG)/gastric (G-tube)

Special Procedures
Does the individual require assistance from paid staff to measure pulse, respiration, blood pressure, temperature, weight,
fluid intake or output, oxygen saturation or glucose levels? Yes No

Does the individual require assistance from paid staff to perform sterile procedures? (e.g., wound care including bed sores,
tracheostomy care/suctioning, urinary catheter placement and care) Yes No

Does the individual require assistance from paid staff to use a CPAP, BiPAP or other oxygen therapy? Yes No
Does the individual require assistance from paid staff to use a vagal nerve stimulator for seizure control? Yes No
Does the individual require assistance from paid staff to administer PRN medication to manage behavior? Yes No

Eating
Does the individual require paid staff to provide intravenous/IV nutrition or NG or G-tube feeding, special diets or additives
(e.g., thickening agents) for oral feeding? Yes No

Does the individual require paid staff to intervene due to a history of frequent choking episodes? Yes No

Bathing
Does the individual require paid staff to bathe him/her using specific bathing techniques because the individual has a
chronic condition (e.g., brittle bone disease, history of aspiration or GERD (gastric reflux), etc.) that would put the individual Yes No
at significant risk for injury if the paid staff were not skilled in the specific bathing techniques?

Toileting
Does the individual require paid staff to perform urinary catheterization, either long term or occasionally? Yes No
Does the individual require paid staff to intervene due to a history of bowel impactions/chronic constipation that required
medical intervention? Yes No

Mobility
Does the individual require paid staff to change his/her position to prevent skin breakdown? Yes No
Does the individual require paid staff to use a mechanical lift to transfer him/her? Yes No
Does the individual require the use of physical or mechanical restraints by paid staff? Yes No

C. Signatures

Signature – Individual or Legally Authorized Representative Date

Signature – Program Provider Representative Date


Form 1572
Page 2 / 05-2019-E

D. Program Provider Review


If “Yes” is the response in Section A, an RN nursing assessment is not required.

Please review the “Yes” responses in Section “B” and document if any of these tasks will be performed by an HCS or TxHmL program provider
staff person. If any of the tasks will be performed by the HCS or TxHmL program provider, an RN nursing assessment must be completed by
the provider’s RN.

In addition, if nursing hours are authorized on the Individualized Plan of Care (IPC), an RN assessment must be completed by the provider’s
RN.

As the program provider for the individual identified above, I have reviewed the information provided and agree that the
documentation regarding nursing tasks is correct and that the individual’s health and safety can be ensured without an RN
assessment by the provider’s RN or nursing services on the individual’s IPC. An assessment by the provider’s RN is not required for
this individual.

As the program provider for the individual identified above, I have reviewed the information provided and, based on the documentation
regarding nursing tasks, have determined the individual’s health and safety CANNOT be ensured without an RN assessment by the
provider’s RN or nursing services on the individual’s IPC.

Signature – Program Provider Representative Title Date

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