[The following is taken from Chapter 4723-4-07 of the Ohio Administrative Code, 2017; http://codes.ohio.gov/oac/4723-4.]

A registered nurse shall apply the nursing process in the practice of nursing as set forth in division (B) of section 4723.01 of the Revised Code and in the rules of the board. The nursing process is cyclical in nature and requires that the nurse’s actions respond to the patient’s changing status throughout the process. The following standards shall be used by a registered nurse, using clinical judgment, in applying the nursing process for each patient under the registered nurse’s care.

Assessment of Health Status

The RN shall, in an accurate and timely manner collect data. This includes:

• Collection of subjective and objective data from the patient, family, significant others, or other members of the healthcare team. The RN may direct or delegate the performance of data collection.
• Documentation of the collected data.

Analysis and Reporting

The registered nurse shall, in an accurate and timely manner:

• Identify, organize, and interpret relevant data;
• Establish, accept, or modify a nursing diagnosis that is to be addressed with applicable nursing interventions; and
• Report the patient’s health status and nursing diagnosis as necessary to other members of the health care team.

Planning

The registered nurse shall, in an accurate and timely manner:

• Develop, establish, maintain, or modify the nursing plan of care consistent with current nursing science, including the nursing diagnosis, desired patient outcomes or goals, and nursing interventions; and
• Communicate the nursing plan of care and all modifications of the plan to members of the health care team.

Implementation

The registered nurse shall, in an accurate and timely manner, implement the current nursing plan of care, which may include:

• Executing the nursing regimen;
• Implementing the current valid order authorized by an individual who is authorized to practice in this state and is acting within the course of the individual’s professional practice;
• Providing nursing care commensurate with the documented education, knowledge, skills, and abilities of the registered nurse;
• Assisting and collaborating with other healthcare providers in the care of the patient;
• Delegating nursing tasks, including medication administration, only in accordance with Chapter 4723-13, 4723-23, 4723-26, or 4723-27 of the Administrative Code.

Evaluation

The registered nurse shall, in an accurate and timely manner:

• Evaluate, document, and report the patient’s response to nursing interventions; and progress towards expected outcomes of the plan of care; and
• Reassess the patient’s health status, and establish or modify any aspect of the nursing plan as set forth in this rule.

For purposes of this rule, standards for implementing the nursing process also apply to a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist.

[The above effective as of 02/01/2014]