Alabama Administrative Code
Title 610 - ALABAMA BOARD OF NURSING
Chapter 610-X-17 - CERTIFIED NURSING SUPPORT TECHNICIAN
Section 610-X-17-.15 - Documentation Standards
Universal Citation: AL Admin Code R 610-X-17-.15
Current through Register Vol. 43, No. 02, November 27, 2024
1. The standards for documentation of care provided to patients by the NST-C are based on principles of documentation, regardless of the documentation format.
2. Documentation of supportive nursing services shall be:
a. Legible.
b. Accurate.
c. Complete. Complete documentation includes
reporting and documenting on appropriate patient record a patient's status,
including signs and symptoms observed if indicated, responses, assistance
provided, bedside testing results, vital signs, NST-C supportive care provided,
communication of pertinent information or changes in patient status to other
health team members and the nurse supervisor, and any unusual occurrences
involving the patient.
(1) A signature of the
writer, whether electronic or written, is required in order for the
documentation to be considered complete. The NST-C shall sign records with the
designation NST-C on the patient record.
d. Timely.
1. Charted at the time or after the care is
delivered. Charting prior to care being provided, including supportive nursing
service skills, violates principles of documentation.
e. A mistaken entry in the record by an NST-C
shall be corrected by a method that does not obliterate, whiteout, or destroy
the entry.
f. Corrections to a
record by an NST-C shall include the name or initials of the individual making
the correction.
Author: Alabama Board of Nursing
Statutory Authority: 34-21-2, Alabama Act No. 2024-249
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