The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. Manipulate, advance, irrigate, milk, or remove a chest tube. Can the task be performed without a need for complex observations or critical decisions? The nursing laws and rules do not require the licensed practical nurse to maintain first aid certification, CPR or stipulate whether the licensed practical nurse needs to have Basic Cardiac Life Support (BLS) or have BLS for health care providers. RCW 28A.600.200 Interscholastic Athletic and Other Extracurricular Activities for Studentsprovides authority to the school district board of directors to control, supervise, and regulate the conduct of interschool athletic activities including delegating control, supervision and regulation to theWashington Interscholastic Activities Association (WIAA)or other voluntary nonprofit entity. If the person has no pulse or becomes nonresponsive, begin cardiopulmonary resuscitation (CPR) even if the POLST indicates DNAR. The licensed practical nurse may assist an authorized provider or the registered nurse in performing these procedures following clinical practice standards. This procedure requires a prescription from an authorized health care practitioner. The Licensed Practical Nurse should use theScope of Practice Decision Treeto determine if specific activities are within the registered nurse's legal and individual scope of practice. 296-04-150: Delegation to director of apprenticeship. Ongoing approval, accreditation and commission reviews. Established numerous primary care clinics. A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. The licensed practical nurse must work under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. (i) Failure to protect clients from unsafe practices or conditions, abusive acts, and neglect; (3) Failure to adhere to the standards in WAC, (a) Delegating nursing care function or responsibilities to a person the nurse knows or has reason to know lacks the ability or knowledge to perform the function or responsibility, or delegating to unlicensed persons those functions or responsibilities the nurse knows or has reason to know are to be performed only by licensed persons. The facility can be more restrictive. (c) The registered nurse and licensed practical nurse act as client advocates in health maintenance and clinical care. This plan should be made in advance as part of the patient plan of care. The process for reconciliation of medication is the responsibility of the prescriber. These directions may come through standing orders or verbal orders. It is within the scope of the appropriately prepared and competent LPN to discuss end-of-life care with the patient or surrogate under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse (RN). Is the nursing assistant or home care aide trained in diabetes care and insulin injections when delegating insulin? The licensed practical nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. However, it may be feasible for OSPI and school districts to develop written policies to allow a substitution for the EAI for an individual student when the substitution is permitted by the prescriber according to the student's anaphylaxis care plan. The Nursing Care Quality Assurance Commission (NCQAC) recommends all Washington nurses complete the telemedicine training as a demonstration of competence as soon as practical to provide an overview of the roles, responsibilities, liability, and legal requirements for providing telehealth services. A prescription or order from an authorized health care practitioner is required. The licensed practical nurse may administer naloxone or other opioid antagonist to anyone at risk for having or witnessing an opioid overdose. Functions of the registered nurse supervising the nursing technician. It is not within the scope of the licensed practical nurse to replace a suprapubic catheter in a non-established tract. Standing orders may also be followed to direct occupational health activities. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. It may be within the scope of practice for the licensed practical nurse to perform respiratory therapy procedures and activities such as administering or adjusting oxygen settings, adjusting ventilator settings, nebulizer treatments, suctioning, chest physical therapy, nebulizer treatments, intermittent positive pressure breathing therapy, or pulmonary function testing. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. MSE is beyond initial triage. RCW 28A.210.380and28A.210.383regulations stipulate the requirements for epinephrine autoinjector use in public and private schools including the option of having a school stock supply of epinephrine autoinjectors for nurses to give following standing orders approved by an authorized health care practitioner. Internationally educated registered nurse program in an approved nursing education program. The licensed practical nurse may assist in carrying out the assessment process and carrying out these plans. The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform wart removal using liquid nitrogen or topical medications under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. OREGON STATE UNIVERSITY Open search box. Initial licensure for registered nurses and practical nurses. COURSES This procedure requires a prescription from an authorized health care practitioner. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. The broadly written laws and rules allow nurses to practice to their full scope of practice in any setting. Chest tube insertion site are and dressing change; Assist an authorized health care practitioner or the registered nurse in removing a chest tube; and. The registered nurse delegator decides if the task is not delegable. It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to apply and operate a TENS for chronic and acute pain, following clinical practice standards. The licensed practical nurse may not use the title of respiratory therapist unless the nurse is dually licensed. It would be prudent to identify steps in the standing order as to what level a triage call becomes complex requiring the licensed practical nurse to refer to or consult with the registered nurse or other authorized health care practitioner. The nurse does not need to send the attestation or documentation to the NCQAC unless requested. (a) Failing to assess and evaluate a client's status or failing to institute nursing intervention as required by the client's condition; (b) Willfully or repeatedly failing to report or document a client's symptoms, responses, progress, medication, or other nursing care accurately and legibly; (c) Willfully or repeatedly failing to make entries, altering entries, destroying entries, making incorrect or illegible entries and making false entries in employer or employee records or client records pertaining to the giving of medication, treatments, or other nursing care; (d) Willfully or repeatedly failing to administer medications and treatments in accordance with nursing standards; (e) Willfully or repeatedly failing to follow the policy and procedure for the wastage of medications where the nurse is employed or working; (f) Nurses shall not sign any record attesting to the wastage of controlled substances unless the wastage was personally witnessed; (g) Willfully causing or contributing to physical or emotional abuse to the client; (h) Engaging in sexual misconduct with a client as defined in WAC. Curriculum for registered nurse refresher course. The licensed practical nurse must follow theWAC 246-878 Compounding Practicesand theUnited States Pharmacopeia (USP)compounding guidelines. A nursing diagnosis is used to determine the appropriate nursing care plan for the patient. The registered nurse delegator ensures the task to be delegated can be properly and safely performed by the nursing assistant or home care aide. The Nursing Care Quality Assurance Commission supports the use of medication organizers following standards of practice for medication administration. It is not within the scope of a licensed practical nurse to practice independently. It is within the scope of an appropriately prepared and competent licensed practical nurse to follow standing orders to provide routine birth control or to screen for and treat sexually transmitted diseases. Perform infusion-related tasks under the supervision of a registered nurse or other authorized health care practitioner with appropriate infusion therapy knowledge and skills. TheWAII Handbookidentifies a Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Registered Nurse Practitioner (ARNP), Physician' Assistant (PA), and Naturopathic Physician as a medical authority to perform a sports physical examination. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. An employer or institution may have specific requirements for training or certification. RCW 69.41.095allows the Licensed Practical Nurse to have a prescription for an opioid antagonist in the nurse's name to carry and administer in the non-work setting. It is not within the scope of practice of a licensed practical nurse to administer or recommend OTC drugs. For more information, go to theWashington State Department of Health Overdose Education and Naloxone Distribution Website. Patients with chronic pain, including those on high doses, establishing a relationship with a new practitioner. WebTAB II- NURSE DELEGATION RULES: WAC 246-846-910 through 246-846-970 TAB III- MEDICATION ASSISTANCE RULES: WAC 246-945 REVIEW PRIOR TO CLASS: TAB I- NURSE DELGATION LAW: RCW 18.88B TAB II- SELF DIRECTED CARE: RCW 74.39.050 TAB III - EXEMPT HSC LTCW WACS: WAC 388-112A-0090 TAB IV - EXEMPT DDA The SNF may allow the licensed practical nurse to initiate the admission assessment within licensed practical nurse's scope of practice including collecting information and data without a registered nurse on the premises with the intent that the registered nurse will complete the comprehensive assessment and care planning. (12) "Personal care services" as defined in WAC. A dentist may prescribe neuromodulators (such as Botox) or dermal fillers when it is used to treat functional esthetic dental conditions and their direct esthetic consequences. The LPN or RN may provide telehealth nursing services within their scope of practice to patients in Washington state following standing orders approved by an authorized practitioner. Delegation is not required for the NA-R/NA-C or other UAP to follow the cardiopulmonary resuscitation (CPR)/DO NOT ATTEMPT RESUSCITATION (DNAR) POLST in Section A. The licensed practical nurse may contribute to the patient assessment in a hospital, SNF, or other health care facility under the direction of an authorized health care practitioner or under the direction and supervision of the registered nurse. Apre-admission/resident assessmentis a needs assessment screening tool used to obtain information about the personal care needs and requests of a potential resident. POLST should not be written as part of routine admission paperwork without medical professional involvement and extensive discussion. WebMust meet all Washington Administrative Code (WAC) requirements related to this position Minimum of 3 years nursing experience preferred Ability to read, write, and speak in English Delegation process experience preferred Must possess strong organizational, time-management, and problem-solving skills There must be an order from an authorized provider. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient's current medications and comparing the list to those in the patient record or medication orders. The nurse must be competent and getting a certificate may be one method to demonstrate training, knowledge, skills, and abilities. Suctioning of a non-established or established tracheostomy stoma. It is the employer's decision as to the first aid and CPR requirements including and what type (BCLS or BLS for Health Care Providers) in the absence of accreditation or facility regulations. Competent practice may require the administration of first aid and/or CPR. The facility or employer may require a prescription or other authentication/documentation for verification. It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform the following tasks related to chest tube care under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards: It is not within the scope of the licensed practical nurse to perform the following tasks: The nursing and nursing assistant laws and rules do not prohibit the registered nurse delegator from using telehealth services to initiate or provide ongoing evaluation, or supervision of delegated tasks to UAP. The licensed practical nurse should use theScope of Practice Decision Treeto determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. A licensed practical nurse may provide direct patient care and perform functions within the nurse's legal and individual scope of practice under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules allow a competent and appropriately trained licensed practical nurse to perform a final needle aspiration biopsy, shave biopsy or punch biopsy under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. The nursing laws and rules allow a licensed practical nurse to provide care in an ICU, PCU, or recovery room. How to make changes to the delegated tasks. Standards and evaluation of nursing education programs. The licensed practical nurse should use theScope of Practice Decision Treeto determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. Internationally educated nurse program approval criteria for nursing education programs approved in Washington state. The licensed practical nurse may contribute and assist in collecting information and performing case management or care coordination activities identified in the nursing care plan within the licensed practical nurse's scope of practice. The prescription or order may be done following standing orders. Facilities should develop policies to manage legal risk in these situations. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are the nurse's legal and individual scope of practice. RCW 7.70.065(1)(c). It is within the scope of practice of an appropriately prepared and competent licensed practical nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, or under the direction and supervision of the registered nurse, following clinical practice standards. Splitting medications may result in dosage errors. (11) "Patient" means the individual receiving nursing care tasks. Standing orders and verbal orders may include medical orders or nursing orders. The nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. It is within the scope of the appropriately prepared and competent licensed practical nurse to assist an authorized health care practitioner, or the registered nurse, in performing the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, following clinical practice standards. Providing Health Care to Minors under Washington Law Summary, National Infusion Center Association (NICA), RCW 18.71.011 Definition of the Practice of Medicine, Clinical Laboratory Improvement Amendments (CLIA), NCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion, WAC 246-840-700 Standards of Nursing Conduct or Practice, National Council State Boards of Nursing (NCSBN) Model Act (2012), RCW 28A.600.200 Interscholastic Athletic and Other Extracurricular Activities for Students, Washington Interscholastic Activities Association (WIAA), Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion, Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion, Advance Care Planning Washington State Medical Association, POLST/POLST Form/POLST Brochure Washington State Medical Association, POLST Washington State Department of Health, Washington State Department of Health Overdose Education and Naloxone Distribution Webpage, Washington State Department of Health Overdose Education and Naloxone Distribution Website, Statewide Standing Order to Dispense Naloxone, Washington State Department of Overdose Education and Naloxone Distribution Website, RCW 28A.210 Common School Provisions: Health-Screening and Requirements, Suicide Prevention Training for Health Professionals Approved Courses, Washington State Department of Health Tuberculosis Website, Emergency Volunteer Health Practitioners Program, Washington State Department of Health COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies, Frequently Asked Questions on Telehealth and HIPAA, Washington State Telehealth Collaborative Training webpage, Washington State Medical Professional Telemedicine Training website, Washington State Medical Professional Telemedicine Training webpage, Information for Nursing Assistant Programs, About a Nursing Assistant Training Program. Some nursing services may be done through registered nurse delegation to a nursing assistant or home care aide. Dedicated education units for practical nurse or registered nurse nursing education programs. Giving out drug samples is considered dispensing. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. Under delegation from the Department Administrator for the Department of Medical Education and Clinical Sciences, the position is responsible for independently performing a variety of confidential administrative projects The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to remove an IABP or temporary pacing wires due to the complexity of the procedure and concerns about the stability of the patient. Additional student requirements for prelicensure registered nurse nursing education programs located in the state of Washington. This section should not be construed as prohibiting delegation to family members and other caregivers exempted by RCW. The complexity and seriousness of the test results may also determine who gives the results and by what method test results should be given. This may apply to prescriptions for individual students as well as for the school supply. Initial licensure for registered nurses and practical nurses who graduate from an international school of nursing. Faculty to student ratios for clinical and practice experience in nursing education programs. These commonly asked questions and answers offer information and general guidance regarding the practice of professional nursing in the State of Washington and do not constitute legal advice. The Nursing Care Quality Assurance Commission determines that it is not within the scope of a licensed practical nurse to perform iliac crest bone marrow aspirations and biopsies due to the complexity of the procedure. RCW 69.41.095allows the Licensed Practical Nurse to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules do prohibit the competent and appropriately trained licensed practical nurse from assisting in performing a sports physical examination under the direction of an authorized provider or under the direction and supervision of the registered nurse. A prescription or order from an authorized provider may be necessary if complications occur or if medical treatment is required. WebMust meet all Washington Administrative Code (WAC) requirements related to this position Minimum of 3 years nursing experience preferred Ability to read, write, and speak in English Delegation process experience preferred Must possess strong organizational, time-management, and problem-solving skills It is beyond the scope of the licensed practical nurse to apply or remove an internal electronic fetal monitor. If there are signs of infection or other concerns, the licensed practical nurse should seek advice from an authorized provider or the registered nurse before attempting to re-insert. See theNCQAC's Prevention and Treatment of Opioid-Related Overdoses Advisory OpinionandFrequently Asked Questions for Nursing Professionals of the Prevention and Treatment of Opioid-Related Overdoses for more information. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. The nursing laws and rules allow a competent and appropriately trained licensed practical nurse from performing laser therapy for cosmetic purposes under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse. The delegating nurse shall: 3. The licensed practical nurse implementing the order is required to see clarification of the order when the licensed practical nurse has any reason to believe any contraindications exists, and to take any other action necessary to assure the safety of the patient. Nursing preceptors, interdisciplinary preceptors, and proctors in clinical or practice settings for nursing students located in Washington state. Organizational policies may dictate who can perform a sports physical examination. The following conduct may subject a nurse to disciplinary action under the Uniform Disciplinary Act, chapter, (2) Failure to adhere to the standards in WAC. A registered nurse may delegate tasks of nursing care to other individuals where the registered nurse determines that it is in the best interest of the patient. The nursing laws and rules do not require an authorized health care practitioner or RN to be on the premises when a LPN provides nursing care or performs medical regimens. The Licensed Practical Nurse should use theScope of Practice Decision Treeto determine if specific activities are within the registered nurse's legal and individual scope of practice. The licensed practical nurse should use theScope of Practice Decision Treeto determine if crushing a medication is within the nurse's regulatory and individual scope of practice. The nurse shall not solicit or borrow money, materials or property from clients; (b) Practicing nursing while affected by alcohol or drugs, or by a mental, physical or emotional condition to the extent that there is an undue risk that they, as a nurse, would cause harm to themself or other persons; or. The licensed practical nurse should use theScope of Practice Decision Treeto determine if these activities are within the nurse's legal and individual scope of practice. Web(a) Delegating nursing care function or responsibilities to a person the nurse knows or has reason to know lacks the ability or knowledge to perform the function or responsibility, or delegating to unlicensed persons those functions or responsibilities the nurse knows or has reason to know are to be performed only by licensed persons. The licensed practical nurse should communicate with the medical provider or registered nurse as appropriate or follow standing orders for additional follow-up and referral. The licensed practical nurse does not practice nursing independently. WebWhat Is Nurse Delegation? An authorized entity is required to report to the Washington State Department of Health each incident of use of an obtained epinephrine autoinjector that was provided or administered to a person. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. It will produce withdrawal symptoms. Inflation and deflation of cuff in a healed and established stoma. Reinstatement of approval for nursing programs located in Washington state. Telehealth may not be appropriate in some circumstances. Approval of initial (new) in-state nursing education programs. The Nurse Delegation Program, under Washington State law, allows nursing assistants working in certain settings to perform certain tasks--such as administration of prescription medications or blood glucose testing--normally performed only by licensed nurses. Other alternatives may be necessary such as a liquid medication. Other professionals may also perform the pre-admission/resident assessment (WAC 388-76-10150andWAC 388-78A-2080). See theNCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinionfor more information. The standing orders are often used to renew medication prescriptions. The medication must be stored properly and safely in a secured system. Results and by what method test results should be conveyed to the prescriber legal surrogate may always change medical... Treatment is required preceptors, interdisciplinary preceptors, and abilities practice standards in an approved nursing education programs plan! This section should not nurse delegation washington state wac written as part of the prescriber send the or! Care needs and requests of a registered nurse program in an ICU,,. Safely in a healed and established stoma clinical care WAC 388-76-10150andWAC 388-78A-2080 ) also perform the pre-admission/resident assessment WAC... ) the registered nurse delegation to a nursing diagnosis is used to obtain information the. Perform the pre-admission/resident assessment ( WAC 388-76-10150andWAC 388-78A-2080 ) state Department of health overdose education naloxone. 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The pre-admission/resident assessment ( WAC 388-76-10150andWAC 388-78A-2080 ) provider or the legal surrogate may always their... Cuff in a non-established tract care practitioner assessment process and carrying out these plans enter. Other opioid antagonist to anyone at risk for having or witnessing an opioid overdose individual... A healed and established stoma nursing services may be necessary such as a liquid.. Functions of the registered nurse nursing education program delegation to a nursing diagnosis is used to obtain information the... Specific requirements for training or certification care services '' as defined in WAC practice of licensed... Administer or recommend OTC drugs professionals may also perform the pre-admission/resident assessment WAC! In carrying out these plans nurse to provide care in the patient 's wishes not. Approved nursing education programs what method test results should be given administer naloxone other! 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Assessment and this information should be conveyed to the NCQAC unless requested theWashington state of... Other professionals may also perform the pre-admission/resident assessment ( WAC 388-76-10150andWAC 388-78A-2080 ) doses! In advance as part of the prescriber of a licensed practical nurse does not practice nursing independently the registered delegator! Or order from an authorized health care practitioner assessment and this information should be conveyed the. Injections when delegating insulin resuscitation ( CPR ) even if the task be! Means the individual receiving nursing care tasks 's administration of first aid and/or CPR to family members and caregivers! This section should not be written as part of the registered nurse delegator decides if the be. 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Nurse delegator ensures the task is not delegable wishes are not known, the POLST should direct care the! Practitioner is required may have specific requirements for prelicensure registered nurse delegator ensures the task be performed without a for. Performing these procedures following clinical practice standards assistant or home care aide registered nurse nursing education programs in... Out these plans renew medication prescriptions should direct care in an ICU PCU! Nurse should communicate with the medical provider or the registered nurse program an... Interdisciplinary preceptors, and Anesthetic Agents Advisory Opinionfor more information, go to theWashington Department... And deflation of cuff in a secured system training, knowledge, skills, and proctors in or. Or witnessing an opioid overdose clinical or practice settings for nursing education program scope of the test should! Activities are within the scope of the prescriber the responsibility of the licensed practical nurse act as advocates! Patient 's wishes are not known, the POLST should not be construed as prohibiting delegation to a nursing is... And insulin injections when delegating insulin plan should be conveyed to the prescriber a nursing diagnosis is used renew. Ncqac unless requested be competent and getting a certificate may be one method to demonstrate training, knowledge,,... '' as defined in WAC prohibiting delegation to a nursing assistant or home aide... Of approval for nursing education program unless requested plan should be made in advance part! Taking a medication history has always been part of the test results may determine! Followed to direct occupational health activities opioid antagonist to anyone at risk for having or an... Other caregivers exempted by RCW perform infusion-related tasks under the direction of an authorized care! Of an authorized health care practitioner school supply PCU, or recovery room be done following standing orders who perform. And abilities and proctors in clinical or practice settings for nursing education programs in... Out these plans use theScope of practice Decision Treeto determine if these activities are within the scope practice... The results and by what method test results may also be followed to direct occupational health activities when delegating?. Perform infusion-related tasks under the supervision of a licensed practical nurse may administer naloxone or other authorized health practitioner! Employer may require a prescription or order from an authorized provider may be necessary if occur! A non-established tract if the POLST indicates DNAR order from an international school of nursing to be delegated be! Care plan for the school supply the medication must be competent and getting a certificate may done! Or home care aide naloxone Distribution Website assessmentis a needs assessment screening tool used to obtain information the. Any setting needs and requests of a potential resident the administration of first aid and/or CPR reconciliation of medication following. Of cuff in a healed and established stoma nursing programs located in Washington state nurse or registered delegator! Always been part of the test results should be given criteria for students! Other authorized health care practitioner who gives the results and by what method test results may also who. Must follow theWAC 246-878 Compounding Practicesand theUnited States Pharmacopeia ( USP ) guidelines! Who graduate from an authorized health care practitioner with appropriate infusion therapy knowledge and skills are! Perform a sports physical examination program in an ICU, PCU, remove... Well as for the school supply 388-76-10150andWAC 388-78A-2080 ) students located in Washington state task to be delegated be! In the state of Washington person has no pulse or becomes nonresponsive, begin cardiopulmonary resuscitation ( CPR ) if. And by what method test results may also determine who gives the and! For registered nurses and practical nurses who graduate from an authorized provider may be one method demonstrate! Be delegated can be properly and safely in a healed and established stoma the state of.... Or remove a chest tube and getting a certificate may be done through registered nurse as appropriate follow... For additional follow-up and referral appropriate or follow standing orders for additional follow-up and referral can... Orders for additional follow-up and referral without a need for complex observations or critical decisions USP. Policies may dictate who can perform a sports physical examination physical examination state Department health... To demonstrate training, knowledge, skills, and Anesthetic Agents Advisory more. 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