Get Dshs 13 678

This guide provides clear and comprehensive instructions for users filling out the Dshs 13 678 form for nurse delegation consent. With step-by-step guidance, individuals will be able to complete the form accurately and efficiently online.

Follow the steps to successfully complete the Dshs 13 678 form online:

1. Press the ‘Get Form’ button to access the Dshs 13 678 form and open it in the editor.
2. Enter the client's name in the designated field, listing the last name followed by the first name.
3. Input the client's date of birth in the format of month, day, and year.
4. Provide the client’s residential address, including street, city, state, and zip code.
5. Enter the telephone number where the client can be reached, including the area code.
6. Indicate the facility or program contact by entering their name; if the client lives at home, enter N/A.
7. If applicable, enter a different telephone number for the facility or program contact.
8. Input the fax number for the facility if available; if not, this can be left blank.
9. Enter the email address of either the client or the facility, if available.
10. Select the appropriate setting by checking the corresponding box.
11. Record the client's diagnoses that relate to the delegated tasks.
12. List any known allergies of the client; if none, write N/A.
13. Provide the name of the client's health care provider.
14. Enter the telephone number for the health care provider, including the area code.
15. Ensure the client or authorized representative signs the form after explaining the nurse delegation process.
16. If the client or representative has a different telephone number, request it be entered here.
17. Record the date of the signature.
18. Obtain verbal consent from the appropriate individual, recording their name and noting that written consent must follow.
19. Specify the relationship of the person who provided verbal consent to the client.
20. Enter the date when verbal consent was obtained.
21. The registered nurse delegate (RND) must print their name in the designated area.
22. Input the RND's telephone number, including the area code.
23. The RND should sign and date the form to verify consent.
24. Review all entries for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your Dshs 13 678 form online today for a smooth nurse delegation process.