Nursing Assessment Protocols

Idaho
Departm ent of
Correction

Standard
Ope rating
Proce dure

Div ision of
Education
T reatme nt
and Re e ntry

Ope rational
Serv ice s
Control Numbe r:
401.06.03.043
Version:
3.0
Page Numbe r:
1 of 5
Adopte d:
2-26-1999

Re v ie we d:
06-10-2013

T itle:

Nursing Asses s m ent Protoc ols
This document was approved by Shane Evans, chief of the Division of Education, Treatment, and Reentry, on 08/07/2013 (signature on file).

Open to the general public: Yes

BOARD OF CORRECTION IDAPA RULE NUM BER 401
Medical Care

POLICY CONT ROL NUMBE R 401
Hos pitaliz ation, Institutional Clinical Services, and Treatm ent

DEFINIT IONS
Standardiz ed Terms and Definitions List

Contract M edical Provider: A private company under contract with the Department to
provide comprehensive m edical, dental, and/or mental health services to the incarcerated
offender population.

Facility Continuous Quality Improvement (COI) Nurse: Contrac t medic al provider
employee who is primarily res pons ible for m onitoring quality assurance.

Facility Health Authority: The contract medical provider employee who is primarily
res pons ible for overseeing the delivery of m edic al services in an Idaho Department of
Correction (IDOC) facility.
Facility M edical Director: The highest ranking phys ician in an Idaho Department of
Correction (IDOC) facility.

Health Authority: The Departm ent employee who is primarily res pons ible for overseeing or
m anaging the Departm ent’s medical and m ental health services. The health authority is
com monly referred to as the health services director.

Health Care Professional: Staff who perform c linical duties, for example, health care
prac titioners, nurs es, soc ial workers, em ergency m edical tec hnic ians, in accordance with
each health care profes s ionals’ scope of training and applicable licensing, certification, and
regulatory requirements.

Standing Order: W ritten orders that spec ify the s ame course of treatm ent of each patient
sus pected of having a given condition and that s pec ify the use and amount of prescription
dr ugs.

Control Numbe r:
401.06.03.043
Version:
3.0
T itle:
Nursing Asses s m ent Protoc ols
Page Numbe r:
2 of 5

PURPOSE
The purpose of this s tandard operating proc edure (SOP) is to es tablish proc edures for (1)
ensuring that nursing assessment protocols are appropriate to the level of s kill and
preparation of the nurs ing personnel who will carry them out, (2) complying with relevant
s tate practice ac ts, and (3) limiting standing orders at the facility to preventive m edic ine
prac tices use only. (National Com m ission on Correctional Health Care [NCCHC] Standard
P-E-11.)

SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) health c are personnel,
offenders, contract m edical providers and subcontractors.

RESPONSIBILITY

Health Authority
The health authority is respons ible for:

Monitoring and overseeing all aspects of health care services, and

The im plementation and continued practice of the provis ions provided in this
SOP.

W hen health care services are privatiz ed, he will also be respons ible for:

Reviewing and approving (prior to im plementation) all applicable contract medical
provider policy, procedure, and form s; and

Monitoring the contrac t medical provider’s performance, to inc lude but not lim ited
to reviewing process es, procedures, form s , and protocols employed by the
contrac t medical provider to ens ure com pliance with all health care-related
requirements provided in res pective contrac tual agreem ents, this SOP, and in
NCCHC s tandard P-E-11. (See sec tion 2 of this SOP.)

Contract M edical Provider
W hen health care services are privatiz ed, the contrac t medical provider is res pons ible
for:

Im plementing and practicing all provis ions of this SOP, unless specifically
exempted by written contractual agreem ents;

Ens uring that all aspects of this SOP and NCCHC standard P-E-11 are
addressed by applicable contract m edical provider policy and proc edure;

Ens uring fac ility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educ ational inform ation to fulfill all health care-
related requirem ents provided in this SOP, NCCHC s tandard P-E-11, or as
indicated in their respective contrac tual agreem ent(s ); and

Ens uring all applicable contrac t medical provider polic y, procedure, and form s
are submitted to the health authority for review and approval prior to
implementation.

Nothing in this SOP shall be construed to relieve the contract m edical provider(s ) of any
obligation and/or res ponsibility s tipulated in res pective contrac tual agreem ents.

Control Numbe r:
401.06.03.043
Version:
3.0
T itle:
Nursing Asses s m ent Protoc ols
Page Numbe r:
3 of 5

Facility M edical Director
The fac ility medical direc tor and fac ility health authority (or designees) will be jointly
res pons ible for:

The annual review of nurs ing asses s m ent protoc ols; and

Establishing a set of institution-specific nurs ing as sessment protocols that specify
the steps to be taken in the ass es s ment, treatm ent, and m onitoring of spec ific
health conditions.

Each protoc ol shall spec ify the level of nursing skill necess ary to apply the protoc ol.

Facility Health Authority
The fac ility health authority will be res pons ible for:

Ens uring the pres ence of an adequate number of appropriately trained staff and
m aterials are available to meet the requirem ents of this SOP;

Establishing and m onitoring applicable contract m edical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standard P-E-11
are acc omplished as required; and

Orienting health c are personnel to the nurs ing as s essment protocols us ed at the
institution.

In addition, to the above res ponsibilities, the fac ility health authority and the fac ility
m edical director (or des ignee) will be jointly res ponsible for:

The annual review of nurs ing asses s m ent protoc ols; and

Establishing a set of institution-specific nurs ing as sessment protocols that specify
the steps to be taken in the ass es s ment, treatm ent, and m onitoring of spec ific
health conditions.

Each protoc ol shall spec ify the level of nursing skill necess ary to apply the protoc ol.

T able of Conte nts
General Requirements ......................................................................................................... 4

1. Introduction .................................................................................................................... 4

2. Guidelines ...................................................................................................................... 4

Monthly Requirements .............................................................................................. 5

Concerns with Protoc ols ........................................................................................... 5

Orientation ................................................................................................................ 5

Training .................................................................................................................... 5

3. Compliance .................................................................................................................... 5

References ........................................................................................................................... 5

Control Numbe r:
401.06.03.043
Version:
3.0
T itle:
Nursing Asses s m ent Protoc ols
Page Numbe r:
4 of 5

GENERAL REQUIREM ENTS

1. Introduction
Nursing asses sment protoc ols are written ins truc tions or guidelines that s pec ify the s teps to
be taken in evaluating a patient’s health s tatus and providing intervention. They also aid
nurs ing s taff and other specific qualified health care profess ionals in the dispos ition of
selected, specific health conditions. Such pr otoc ols m ay inc lude acceptable firs t-aid
procedures for the identification and c are of ailments that ordinarily would be treated by an
individual with over-the-c ounter medic ation or through self-care.

Nursing asses sment protoc ols may also address m ore serious sym ptoms such as chest
pain, shortness of breath, or intoxication.

Nursing asses sment protoc ols fac ilitate the initiation of treatment of identified conditions and
ensure appropriate referral.

2. G uide line s
Each nurs ing asses s ment protocol shall be written in acc ordance with the Idaho
Nurse Prac tice Act and m ust spec ify level of s kill and preparation of health care
personnel privileged to use the protoc ol. Al l nursing ass es s ment protoc ols shall be
forwarded to the health authority, following the annual review at the institution level,
for review and approval.

Nursing asses sment protoc ols will be kept in a m anual in all health c are areas where
nurs ing s taff and other qualified health care professionals will provide care in
acc ordance with the protoc ols.

Subjective and objective areas lis ted in the nurs ing ass es s m ent protoc ol s hould be
ass essed and appropriate positive/negative findings doc um ented in the progress
notes. The asses s ment, plan, and patient educ ation provided are also to be
documented in the progress notes according to the nurs ing asses s m ent protocol.

Each entry is to be rec orded in the subjective, objective, assessm ent, plan (SOAP )
charting format; s igned; dated; and timed.

If the ass es s ment indicates that orders for treatm ent are to be initiated, these are to
be written on the order s heet exactly as outlined in the nurs ing ass es s ment protocol.

If the deviation from treatm ent listed in the protoc ol is necess ary, the nurse or other
qualified health care profess ional m us t obtain an order from the res ponsible
physic ian, dentist, nurse prac titioner or phys ician assis tant.

Multiple applications of the same order on the s ame patient should be reviewed by
the physic ian or m id-level provider.

The health care rec ord of any offender for whom treatment was initiated under a
written protoc ol that inc ludes orders for a legend drug or diagnos tic procedure, will
be reviewed by a phys ician, dentis t, physic ian as s istant or nurse prac titioner (as
approved by the fac ility m edical director) within 72 hours. The phys ician or
prac titioner will review and initial the progress note written by the nurse and
countersign the order.

For the purpose of health care rec ord c larity, the review and counter s igning shall be
dated and tim ed.

Control Numbe r:
401.06.03.043
Version:
3.0
T itle:
Nursing Asses s m ent Protoc ols
Page Numbe r:
5 of 5

M onthly Requirements
The nursing s taff’s use of nursing asses s ment protocols will be reviewed on a m onthly
basis by the COI nurse.

Concerns with Protocols
Concerns with the use of nurs ing asses sm ent pr otoc ols shall be address ed with the
fac ility health authority.

O rientation
Orientation to the nurs ing asses s m ent protoc ols us ed at each institution will be
documented and shall inc lude, at a minim um :
Evidence that the nurse or other qualified health care professional was trained;
Doc umentation that the nurse or other qualified health care pr ofessional is able
to dem onstrate knowledge and s kills pertinent to the protocols ;

Doc umentation of annual review of s kills and knowledge that are required to
utiliz e the protoc ols. (Note: This occurs during annual perform ance evaluations
and as needed based on the fac ility m edical direc tor and fac ility health authority’s
observation.); and

Doc umentation of training when new protoc ols are introduc ed or existing
protoc ols are revised.

Training
Nurses, and other qualified health c are professionals who are permitted by Idaho Code
to provide as pects of nurs ing care, shall be trained to provide clinical services and will
provide such services under specified guidelines.

3. Compliance
Compliance with this SOP and all related departm ent-approved protoc ols will be monitored
by the health authority (or designee) by us ing various sources to include: this SOP, c linical
prac tice guidelines, routine reports , program reviews, and rec ord reviews.

The health authority (or des ignee) must conduc t two (2) audits per year (or more frequently
as des ired based on prior audit res ults ). The audits m ust cons ist of m onitoring applicable
contract m edical provider and IDO C policy and proc edures, applicable NCCHC standards ,
and the review of a minim um of 15 individual rec ords.

REFERENCES
National Com mission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons , Standard P-E-11, Nursing Assessment Protoc ols

– End of Doc um ent –