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It is within the scope of practice of an appropriately trained and competent registered nurse to perform tracheostomy care under the direction of an authorized health care practitioner, following clinical practice standards, including:

The registered nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission’s Neonatal Intubation and Related Procedures Advisory Opinion for additional information.

It is within the scope of practice of an appropriately trained and competent registered nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized provider, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. There may be other regulations, such as Centers for Medicare and Medicaid Services (CMS) who defines the requirements for supervision (general or direct), and other parameters, for reimbursement of the procedure.

It is within the scope of practice of an appropriately trained and competent registered nurse too perform endotracheal intubation, laryngeal mask placement, or other resuscitative procedures under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. Standing orders may be used. See the Nursing Care Quality Assurance Commission’s Neonatal Intubation and Related Procedures Advisory Opinion and Standing Orders and Verbal Orders Advisory Opinion for additional information.

It is within the scope of practice of an appropriately trained and competent registered nurse to perform a routine and non-complex cardiac stress test under the direction of an authorized provider, following clinical practice standards. A prescription or order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately trained and competent registered nurse too perform respiratory therapy procedures, It may be within the scope of practice for the registered 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. Medical regimens require a prescription or order from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree may not use the title of respiratory therapist unless the nurse is dually licensed.

It is within the scope of practice of the appropriately prepared and competent registered nurse from removing an IABP or temporary pacing wires under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse to perform the OSHA Respirator Medical Evaluation Questionnaire and perform a respiratory fit test, under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. Please see the regulations for OSHA Respirator Medical Evaluations. The registered nurse may perform the evaluation and/or respiratory fit testing following standing orders. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

It is within the scope of practice of the appropriately prepared and competent registered nurse to perform needle decompression for a tension pneumothorax under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of practice of the appropriately prepared and competent registered nurse to remove trans-thoracic (epicardial) pacing wire following open-heart surgery under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules do not require the registered nurse maintain first aid certification, CPR or stipulate whether the registered nurse needs to have Basic Cardiac Life Support (BLS) or have BLS for health care providers. The laws and rules require nurses to demonstrate competence and accountability in all areas of practice in which the nurse is engaged. The registered nurse should consider the area of practice in which the nurse is working. Competent practice may require the administration of first aid and/or CPR. Employers or facilities may require the registered nurse to maintain first aid and/or CPR certification. Some facility laws and rules require nurses to have a CPR certification. For example, WAC 246-320 Hospital Licensing Regulations require at least one nurse to have CPR and at least one nurse to have advanced cardiac life support (ACLS) in recovery areas and in critical care units. In neonatal and pediatric services in hospitals, at least one registered nurse and physician must be trained in infant/pediatric resuscitation; in obstetrics, at least one registered nurse must be trained in neonatal resuscitation when infants are present. WAC 246-330 Ambulatory Surgical Facilities require at least one registered nurse to have current ACLS certification. WAC 388-112-0260 Adult Family Homes and Assisted Living Facilities also have specific requirements for CPR and first aid training. The Centers for Medicaid and Medicare Services (CMS) and accreditation organizations (such as the Joint Commission) may have specific requirements. 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. The employer may also decide whether they want to require an in-person course or on-line course and other parameters.

It is within the scope of practice of the appropriately prepared and competent registered nurse to perform the following tasks related to chest tube care under the direction of an authorized health care practitioner, following clinical practice standards:

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 nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79,  WAC 246-840, RCW 18.88A, WAC 246-841).

The Washington State Department of Social and Health Services issued the following policies related to COVID-19, telehealth services, and delegation requirements:

The nursing laws and rules allow a competent and appropriately trained registered nurse from administering neuromodulators (such as Botox®, Dysport®, or Xeomin®). These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within nurse’s legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner to be on the premises when a nurse provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-606 Nonsurgical Medical Cosmetic Procedures applies to nonsurgical medical cosmetic procedures that involve the injection of a medication or substance for cosmetic purposes, or use of a prescriptive device for cosmetic purposes (except for laser, light, radiofrequency and plasma devices). These rules allow delegation of these procedures to a properly trained registered nurse. The delegating physician need not be on the premises during the procedure, but the physician must be reachable by telephone to be able to respond within thirty minutes to treat complications. The Nursing Care Quality Assurance Commission recommends following the WAC 246-919-606 for physicians when carrying out these procedures.

The nursing laws and rules allow a registered nurse to take direction for a medical regimen from a dentist or other authorized health care practitioners within their scope of practice. 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. See the Dentist Scope of Practice - Use of Botulinum Toxin Injections/Dermal Fillers Interpretive Statement for more information

The nursing laws and rules allow a competent and appropriately trained registered nurse from performing laser therapy for cosmetic purposes. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within nurse’s legal and individual scope of practice. The nursing laws and rules do not require an authorized health care practitioner to be on the premises when a nurse provides nursing care or performs medical regimens. However, the Medical Quality Assurance Commission WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin includes language and requirements for physicians. The rules allow delegation to a properly trained and licensed professional and require a physician to be on the immediate premises during the patient’s initial treatment. The authorized health care practitioner may provide treatment following an established treatment plan during temporary absences of the prescribing physician provided there is local back-up physician who will be available by telephone and see the patient within sixty minutes. The Nursing Care Quality Assurance Commission recommends the nurse follow the WAC 246-919-605 for physicians when carrying out laser treatment procedures under the direction of an authorized health care practitioner.

A registered nurse does not require additional licensure as an esthetician to perform laser therapy for cosmetic purposes.

The laws and rules do not require a special certificate to perform cosmetic procedures. The nurse must be competent and getting a certificate may be one method to demonstrate training, knowledge, skills, and abilities. A facility or employer may require a specific certification or training program.

The nursing laws and rules allow a competent and appropriately trained registered nurse from applying eyelash extensions as an intervention based on nursing assessment, nursing diagnosis, or under the direction of an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The Food and Drug Administration (FDA) approves cosmetics. No color additives are approved by the FDA for permanent dyeing or tinting of eyelashes or eyebrows. False eyelashes and extensions, as well as their adhesives, must meet the safety and labeling requirements for cosmetics. See the Food and Drug Administration’s website, Using Eye Cosmetics Safely, for more information.

The nursing laws and rules allow a competent and appropriately trained registered nurse from applying medications, such as Latisse® (a prescriptive medication), used for eyelash growth. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from applying superficial chemical peels or microdermabrasion. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from performing medical tattooing, permanent makeup application, body piercing, and electrolysis. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from applying cold therapy (cryotherapy) heat therapy for fat removal. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from performing wart removal using liquid nitrogen or topical medications. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from performing phototherapy such as Type B Ultraviolet (UVB), Grenz Ray, or Psoralen and Long-Wave Ultraviolet Radiation (PUVA). These procedures require a prescription from an authorized health care practitioner.  The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse from performing a fine needle aspiration biopsy, shave biopsy, or punch biopsy. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse to administer intralesional injections. This procedures requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to 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 registered nurse to perform electrodessication and curettage. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing law and rule does not prohibit a competent and appropriately trained registered nurse from administering any medication – legend or controlled substance (Schedule II-IV) or over-the-counter medications. The registered nurse may administer medications by any route. The registered nurse must be competent and follow the standards for medication administration.

Receiving telephone and verbal prescription orders, transcribing, and transmitting prescription orders are activities often performed by nurses and appropriately included by many organizations in the responsibilities of the registered nurse. The registered nurse has the skill and knowledge to receive a prescription order and transcribe it accurately for other nurses to implement or transmit the order to a pharmacist to dispense. The laws and rules do not prohibit the registered nurse from calling in medication orders except for those restrictions in the Controlled Substances Act. The registered nurse may enter medication prescriptions into an electronic health system under the direction of an authorized health care practitioner. These directions may come through standing orders or verbal orders. Standing orders are often used to renew medication prescriptions. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. It is within the scope of practice of the appropriately prepared registered nurse to write or enter the information into an electronic health record system the patient demographic information, as well as the drug, dosage, frequency and number of refills on a medical prescription as pursuant to a medical order. The nurse may not sign the nurse's name or the name of the individual authorizing the prescription on the prescription. WAC 246-870 Electronic Transmission of Prescription Information allows electronic prescriptions for legend drugs and controlled substances (except for Schedule II controlled substances). The laws states, “The system shall provide an audit trail of all prescriptions electronically transmitted that documents for retrieval all actions and persons who have acted on a prescription, including authorized delegation of transmission.” The order must be authenticated. See the Washington State Department of Health Pharmacies Website for more information.

It is not within the scope of practice for the registered nurse to renew an existing medication without a new prescription from an authorized health care practitioner. A competently and appropriately trained registered nurse may follow standing orders or verbal orders to renew an existing medication. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.

Giving out prescription drug samples is considered dispensing. It may be within the scope of practice of the competent and appropriately trained registered nurse to dispense pre-packaged a prescription sample that is properly labeled by an authorized health care practitioner or pharmacist. The registered nurse needs to be competent regarding the specific medication including the indications, contraindications, and side effects that is being delivered to the patient. The registered nurse should use the Scope of Practice Decision Tree to determine if handing out a pre-labeled, pre-packed sample is within the registered nurse’s regulatory and individual scope of practice. See the NCQAC's Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion for more information.

The competent and appropriately trained registered nurse may compound medications under the direction of an authorized health care practitioner. A prescription or order from an authorized health care practitioner is required. The registered nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The registered nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications is within the registered nurse’s regulatory and individual scope of practice.

It may be within the scope of practice of the competent and appropriately trained registered nurse to prepare allergenic extracts as compounded sterile preparations under the direction of an authorized health care practitioner.  A prescription or order from an authorized health care practitioner is required. The registered nurse must follow the WAC 246-878 Compounding Practices and the United States Pharmacopeia (USP) compounding guidelines. The registered nurse should use the Scope of Practice Decision Tree to determine if performing compounding medications and preparing allergenic extracts is within the registered nurse’s regulatory and individual scope of practice. See the Compounding Medications by Licensed Practical Nurses, Registered Nurses, and Advanced Registered Nurse Practitioners Advisory Opinion for more information.

The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from administering medications following standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if administering medications following a specific standing order within the registered nurse’s regulatory and individual scope of practice.

The process for reconciliation of medication is the responsibility of the prescriber. It is important to remember that the registered nurse is not authorized or approved to sign orders that must be reconciled with patient medication. 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 purpose of reconciliation is to avoid errors that include but are not limited to transcription, omissions, duplication, dosing errors, or drug interactions. Taking a medication history has always been part of the nursing assessment and this information should be conveyed to the prescriber. The NCQAC suggests the following:

It may be within the scope of practice of the competent and appropriately trained registered nurse to administer and “read” the tuberculosis (TB) skin test under the direction of an authorized health care practitioner. A prescription or order from an authorized provider is required as TB skin test formulations are a legend drug. Standing orders may be used. The registered nurse should use the Scope of Practice Decision Tree to determine if this activity is within the regulatory and individual scope of practice. The order may be made using a standing order.  The prescriber or the registered nurse does not need to be on the premises when the registered nurse is administering medications. The registered nurse should communicate with the medical provider as appropriate or follow standing orders as appropriate for additional follow-up and referral.  The Nursing Care Quality Assurance Commission recommends the registered nurse follow the Washington State Tuberculosis Laws and Guidelines and the Centers for Disease Control Guidelines for TB Screening and Follow-Up. Refer to the Standing Order Advisory Opinion for more information on use of standing orders.

The NCQAC supports the use of medication organizers when using the standards of practice of medication administration. It is acceptable for the registered nurse to prepare a medication organizer or individual pill containers under the following conditions:

See the Advisory Opinion on Medisets, the Medication Organizer Device Letter from Secretary of Health (PDF), and the Medication Organizer Device (PDF) for more information.

The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving off-label medications under the direction of an authorized provider. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The Food and Drug Administration Understanding Unapproved Use of Approved Drugs "Off-Label" website provides information about using unapproved off-label drugs. Off-label use should be done with careful insight and understanding of the risks and benefits to the patient considering high-quality evidence supporting efficacy, effectiveness, and safety. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.

The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving drugs, including antineoplastic drugs under the direction of an authorized provider. he facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the off-label medication is within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.

The state and federal laws and regulations do not require the registered nurse to have a special certification to give chemotherapy in the home setting. he facility or employer may require a specific certification or training program. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of the chemotherapy is within his or her regulatory and individual scope of practice.

The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from giving experimental drugs by any route under the direction of an authorized provider. The registered nurse be competent. The facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of experimental drugs is within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.

The label will suffice if the label completed following state law, is legible, properly identified, has the name of the patient on it, and the medication prescription has not expired. The facility or employer may require a prescription or other authentication/documentation for verification. The registered nurse is always responsible for verifying the order with the prescriber if there are concerns.

The registered nurse works under the direction of an authorized health care practitioner within the practitioner’s scope of practice. The registered nurse may administer medications and perform treatments or procedures without an authorized health care practitioner on the premises. A prescription or order from an authorized provider is required for legend drugs, controlled substances or for medical treatments.

A pharmacist is not identified as an authorized health care practitioner that the registered nurse may take orders or direction from. This does not mean the registered nurse may not work in a pharmacy setting administering immunizations. It is acceptable for orders for immunizations to be made by an authorized health care practitioner using standing orders. See the NCQAC Standing and Verbal Orders Advisory Opinion for guidelines and recommendations.

The nursing law and rule does not prohibit a registered nurse in making a decision to crush or split medications without an order. A registered nurse can use nursing judgment. The employer may have policies or guidelines about crushing or splitting medications. The registered nurse should use the Scope of Practice Decision Tree  to determine if crushing a medication is within the registered nurse’s regulatory and individual scope of practice. The registered nurse should make the decision whether or not to crush or split the medication based on patient needs, prescribing information by the provider, and safety of the medication being administered in this form. The registered nurse administering the medication is responsible for ensuring the medication is safe to crush or split before giving it. Follow-up with the prescribing provider is warranted if a medication order states to crush or split the medication is necessary but it is not recommended. Other alternatives may be necessary such as a liquid medication. The Institute for Safe Medication Practices (ISMP) is a good resource for determining whether a medication is safe to crush. Splitting medications may result in dosage errors. Not all medications may be split. The registered nurse needs to determine whether the medication can be safety split to ensure proper dosage. The registered nurse should consider consulting with a pharmacist and follow current guidance or standards and/or contact the prescriber or pharmacist to see if there is another alternative, such as liquid form or getting the medication in the appropriate dose.

The nursing laws and rules do not address this question. Some facility laws do address medication refusal. The WAC 388-76 Adult Family Home Minimum Licensing Requirements addresses medication refusal: WAC 388-76-10435 Medication Refusal. Hiding medications and not notifying the patient may be a violation of patient rights. See the Washington State Department of Health Patient Rights Guidelines for more information.

The registered nurse may carry and administer epinephrine under the direction of an authorized health care practitioner. The registered nurse may not administer epinephrine without an order from an authorized health care practitioner. The order or prescription may be for a specific patient or through the use of standing orders. Another option is for the facility or employer to become an authorized entity. SSB 6421 was passed in 2016 allowing authorized entities to obtain epinephrine autoinjectors. This allows an authorized health care practitioner to issue a prescription made out in the name of the authorized entity. Authorized entities that choose to acquire epinephrine autoinjectors must have people connected with the entity, such as employees, who have completed an anaphylaxis and epinephrine autoinjector training. These people will be responsible for the storage, maintenance, and general oversight of the epinephrine autoinjectors. They may administer or provide an epinephrine autoinjector to people who are experiencing anaphylaxis. 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. Other laws may apply depending on the setting. RCW 28A.210.380 and 28A.210.383 regulations 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. See the Washington State Department of Health’s Epinephrine Autoinjectors and Anaphylaxis Training and Reporting for Authorized Entities Frequently Asked Questions  and the SSB 6421 Status Update Document for more information.

The registered nurse may administer naloxone or other opioid antagonist to anyone at risk for having or witnessing an opioid overdose. See the NCQAC's Prevention and Treatment of Opioid-Related Overdoses Advisory Opinion and Frequently Asked Questions for Nursing Professionals of the Prevention and Treatment of Opioid-Related Overdoses for more information.

The laws and rules do not prohibit the competent and appropriately trained registered nurse from implementing a drug order that has a dosage range. The medical provider makes the "medical judgment" as to the specific medication and dosage. The registered nurse is given the latitude to use "nursing judgment" in determining the amount to be administered based on the patient’s clinical status. The registered nurse must apply adequate knowledge and skills in determining the dosage to be administered at any given time. Appropriate documentation of a focused patient assessment and evaluation must substantiate intervention. It is recommended that medication orders be patient/condition specific even if prescribed pro re nata (PRN), when needed. This would take away some of the notion of the nurse "prescribing" the medication. There should be some consultation with the physician to initiate a standing order particularly if the signs/symptoms are deviations from the patient's norm. Standing orders are certainly not to be used in lieu of medical consultation or intervention. Range orders should ideally consist of:

The state laws and rules do not prohibit the competent and appropriately trained registered nurse from assisting in providing case management and support for patients in MAT within the registered nurse’s legal and individual scope of practice. The Drug Enforcement Administration (DEA) does state that, “an individual (secretary or nurse) may be designated by the practitioner to prepare prescription for the practitioner’s signature.”

The nursing law and rules do not prohibit the competent and appropriately trained registered nurse from administering intra-articular injections under the direction of an authorized provider. he facility can be more restrictive. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if the administration of intra-articular injections with within his or her regulatory and individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides.

The registered nurse may destroy, witness, and/or cosign the destruction of wasting of controlled substances in a SNF home. See the WAC 246-865-060 Pharmaceutical Services-Extended Care Facility for more information. See the WAC 246-874-050 Accountability Requirements for an Automated Drug Dispensing Device (ADDD) if using an ADDD.

The law and rules do not prohibit the registered nurse from administering or recommending OTC drugs as an intervention based on the nursing process, including nursing assessment, nursing diagnosis, and nursing evaluation. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if this activity is within the individual scope of practice. The registered nurse is always individually accountable and responsible for the nursing care the registered nurse provides. Facilities or employers may be more restrictive.

It is within the scope of practice of an appropriately trained and competent registered nurse to insert a feeding tube in a neonate, infant, child, or adult under the direction of an authorized health care practitioner, following clinical practice standards. An order from an authorized health care practitioner is required. The registered nurse should use the Scope of Practice Decision Tree.

It is within the scope of practice of an appropriately trained and competent registered nurse to insert a PEG tube under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately trained and competent registered nurse to manipulate the endoscope when assisting in performing an endoscopic procedure. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately trained and competent registered nurse to perform an endoscopy, sigmoidoscopy, or colonoscopy procedures, including obtaining biopsies, following clinical practice standards. Standing orders from an authorized health care practitioner may be used to order the procedure and for follow-up actions based on the results. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. Facility policies, accreditation organizations (such as the Joint Commission), and Federal regulations (such as the Centers for Medicare and Medicaid Services) may limit or restrict the scope of practice of registered nurse performing this procedure.

It is within the scope of practice of an appropriately trained and competent registered nurse to perform ostomy care, following clinical practice standards. Routine care of a stoma should be addressed in the nursing care plan. A prescription or order from an authorized provider may be necessary if complications occur or if medical treatment is required. Generally, a prescription from an authorized health care practitioner is required for reimbursement of medical supplies. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately trained and competent registered nurse to re-insert a gastrostomy tube in a mature stoma site under the direction of an authorized health care practitioner, following clinical practice standards. If there are signs of infection or other concerns, the registered nurse should seek advice from an authorized provider before attempting to re-insert. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

The RCW 18.79 Nursing Care and the WAC 246-840 Practical and Registered Nursing allow a nurse to employ their full scope of practice in multiple settings. NCQAC also approves advisory opinions and interpretive statements about specific nursing practice questions. The NCQAC recommends the registered  nurse use the Scope of Practice Decision Tree to determine if an activity is within the nurse’s scope of practice.

The registered nurse practices nursing care independently. The registered nurse practices interdependently taking direction from an authorized health care practitioner when carrying out medical regimens.

The registered nurse may work in any setting where nursing care is provided. Examples of settings include (but not limited to): Hospitals, nursing homes, assisted living facilities, adult family homes, schools, camps, clinics, public health clinics, homes, hospice, community health centers, homeless shelters, insurance companies, law offices, travel clinics, occupational health centers, private clinics, outpatient clinics, ambulatory surgery centers, dialysis centers, mental health centers, infusion centers, medical spas, nursing informatics programs, correctional centers/jails, county health departments, government offices, cruise ships, churches, casinos, retail clinics and other businesses.

Most health care facilities or employers include an organizational structure that defines a person’s manager or supervisor. A non-nurse may be a “supervisor” of the registered nurse in an organizational structure related to human resource and administrative functions. This is different than the definition of “supervision” of a nursing activity. The nursing rules define “supervision” as the “provision of guidance and evaluation for the accomplishment of a nursing task or activity with the initial direction of the task or activity; periodic inspection of the actual act of accomplishing the task or activity; and the authority to require corrective action.” The registered nurse practices independently and does not require supervision or evaluation of nursing care. Only the registered nurse or advanced registered nurse practitioner may supervise and evaluate the practice of nursing.

The nursing law and rule does not require an authorized health care practitioner to be on the premises when the registered nurse provides care in any setting. A facility or supervisor may require direct or immediate supervision of specific activities or if there are concerns about competency for a specific nurse. An exception exists in the physician rules that require a physician to be on the immediate premises during the patient’s initial treatment when a nurse is performing laser therapy: WAC 246-919-605 Use of Laser, Light, Radiofrequency, and Plasma (LLRP) Devices as Applied to the Skin.

The employer may not expand the registered nurse’s scope of practice. The registered nurse must provide nursing care within Washington statutes and regulations that govern nursing practice.

An ALF may choose to provide, but is not required to provide, intermittent nursing services. The registered nurse may provide nursing care and in an ALF within the registered nurse’s scope of practice and carryout medical regimens under the direction of an authorized health care practitioner. Only the registered nurse may delegate nursing activities to a nursing assistant-certified (NA-C), nursing assistant-registered (NA-R), or home care aid-certified (HCA-C) in an ALF. See the RCW 18.20 Assisted Living Facilities and WAC 388-78A Assisted Living Facility Licensing Rules for more information.

The general age of majority for health care is eighteen years old in Washington State as defined in RCW 26.28. Other laws do allow exceptions for specific types of treatment: See the Providing Health Care to Minors under Washington Law Summary for more information.

It is not in the scope of practice for a registered nurse to make a medical diagnosis based on interpretation of diagnostic test results. Medical test results must be interpreted by an authorized health care practitioner. The nursing laws and rules do not prohibit the registered nurse from relaying test results or a medical diagnosis if already made by an authorized health care practitioner. It is important to consider what types of questions or discussion the patient might have when receiving test results or when a diagnosis is relayed to the patient by the nurse. Abnormal test results should be communicated by someone who can provide supporting information about the test, implications, and follow-up care. The complexity and seriousness of the test results may also determine who gives the results and by what method test results should be given.  The person giving the test results or diagnosis must be competent to answer the patient’s questions.

The nursing laws and rules do not require a registered nurse to get a special certification to perform infusion therapy, phlebotomy, or laboratory tests. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the competent and appropriately trained registered nurse from performing infusion therapy. Invasive procedures require an order from an authorized health care practitioner. It may be within the scope of practice of a registered nurse to perform the following tasks related to a VAD or other infusion devices under the direction of an authorized health care practitioner:

The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The nurse must follow clinical standards of care. Examples include the Infusion Nurses Society (INS) and the National Infusion Center Association (NICA) practice, training, and competency standards for the registered nurse.

It is not within the scope of practice for a registered nurse to start an intravenous line without an order from an authorized health care practitioner. The RCW 18.71.011 Definition of the Practice of Medicine stipulates the practice of medicine to include severing or penetrating the tissues of human beings. Standing orders may be an option to allow the nurse to start an intravenous line based on specific criteria (such as a high acuity patient), admission to a specific unit (such as intensive care), or for a specific condition. Standing orders may also be used to allow a nurse to start more than one intravenous line based on specific criteria. The nurse must be competent to carry specific steps identified in the standing order. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.

A registered nurse does not need an additional order from an authorized health care practitioner to restart an intravenous line that is no longer patent. The nurse may want to consult with the authorized health care practitioner in situations when the nurse is unsure if the patient still requires an intravenous line or if the patient’s intravenous line is insufficient to support the therapy needed.

The nursing laws and rules allow the competent and appropriately trained registered nurse to administer stem cell-based products via a peripheral intravenous line, intra-arterial catheter, intradermal technique, or intramuscular technique, intravitreal infusion, retrobulbar infusion, spinal infusion, or other complex administration techniques. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the competent and appropriately trained registered nurse to perform venipuncture to obtain blood samples for laboratory testing in any setting. These procedures require a prescription from an authorized health care practitioner. The nurse must follow Federal and State blood-borne pathogen and Scope of Practice Decision Tree to determine if these activities are within the nurse’s regulatory and individual scope of practice.

It is not within the scope of the registered nurse to make a medical diagnosis – CLIA waived tests are considered screening (not diagnostic tests). The nursing laws and rules allow the competent and appropriately trained registered nurse to perform tests such as a human chorionic gonadotropin (hCG), urine dipstick, strep throat screening, occult blood screening, blood glucose capillary tests or other CLIA approved waiver under the CLIA criteria. An order is required from an authorized health care practitioner to perform any activity that involves puncturing the skin as this is considered part of the definition of the practice of medicine. The CLIA waived tests that do not involve puncturing the skin may be initiated by a registered nurse without an order from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the of the competent and appropriately trained registered nurse from obtaining and submitting capillary or venous blood specimens for lead screening, hepatitis B screening or other employee health tests. An order is required from an authorized health care practitioner for laboratory tests involving puncturing of the skin. Standing orders may also be followed to direct occupational health activities. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the competent and appropriately trained registered nurse from obtaining an arterial blood gas directly from an artery or through an arterial line. This procedure requires a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the competent and appropriately trained registered nurse from obtaining an iliac crest bone marrow aspiration and biopsies. These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

The nursing laws and rules allow the competent and appropriately trained registered nurse from performing therapeutic phlebotomy for conditions (such as polycythemia vera). These procedures require a prescription from an authorized health care practitioner. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

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 should use the Scope of Practice Decision Tree to determine if performing these activities is within the licensed practical nurse's regulatory and individual scope of practice.

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

It is within the scope of practice of the appropriately prepared and competent licensed practical nurse to perform an EEG or EMG under the direction of an authorized health care practitioner or under the direction and supervision of a registered nurse, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

The Nursing Care Quality Assurance Commission determines it is beyond the scope of the licensed practical nurse to lead this activity due to the complexity of the procedure. The licensed practical nurse may assist an authorized health care practitioner or the registered nurse in performing a lumbar puncture, following clinical practice standards. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if these activities are within the licensed practical nurse's legal and individual scope of practice.

It is within the scope of practice of the appropriately prepared and competent registered nurse to apply and operate a TENS for chronic and acute pain, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if performing these activities is within the registered nurse’s regulatory and individual scope of practice.

It is within the scope of practice of the appropriately prepared and competent registered nurse to perform a lumbar puncture, including obtaining laboratory specimens, under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

It is within the scope of practice of the appropriately prepared and competent registered nurse to perform an EEG or EMG under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

A pre-admission/resident assessment is a needs assessment screening tool used to obtain information about the personal care needs and requests of a potential resident. The pre-admission/resident assessment findings may identify needs for a comprehensive nursing care assessment.

A nursing care assessment gathers information about the person’s health status through the collection of data and/or physical examination. This assessment includes the use of the nursing process (WAC 246-840-700). Although a nursing care assessment may include elements of a non-skilled personal care assessment, it is a comprehensive nursing care evaluation and must be performed by the registered nurse. The licensed practical nurse may assist in gathering information for the nursing care assessment under the direction and supervision of the registered nurse.

The laws and rules found in Aging and Adult Service Section of WAC 388-78A (assisted living facilities) and 388-76 (adult family homes) define the qualifications required for an individual to perform the required pre-admission/resident assessment. An individual with a nursing license (licensed practical nurse or registered nurse) meets the qualifications to perform the pre-admission/resident assessment. Other professionals may also perform the pre-admission/resident assessment (WAC 388-76-10150 and WAC 388-78A-2080).

This pre-admission/resident assessment (screening tool) does not necessarily require the services of a professional licensed nurse or the use of the nursing process (WAC 246-840-700). The goal of the pre-admission/resident assessment is to determine the personal care services needs of a potential resident and at times, the nursing care needs of said resident. If a comprehensive nursing assessment is contemplated as part of the care plan, the registered nurse must undertake that portion of the pre-admission assessment.

Staff must meet the credentialing, training and competency requirements established in the state and federal laws and rules specific to the setting. Training and competency assessment for personal care services (non-nursing care) does not require the services of a Washington state licensed professional nurse. Training and education of staff employed in these facilities that address personnel, performance and other administrative activities do not require the utilization of a registered nurse.

Nursing assessment may include a comprehensive nursing assessment. A comprehensive nursing assessment means collection, analysis, and synthesis of data performed by the registered nurse used to establish a health status baseline, plan care and address changes in a patient’s condition as defined in the National Council State Boards of Nursing (NCSBN) Model Act (2012) (PDF).

The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from initiating the admission of a patient to a hospital or SNF. Joint Commission Nursing Assessment standards require the registered nurse to perform the nursing assessment within twenty-four hours after admission to a hospital. The nurse should be aware that other laws and rules may apply such as facility laws and rules or the Centers for Medicare and Medicaid regulations.

The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from performing a pre-anesthesia assessment. It is expected that the registered nurse would complete an appropriate age-specific nursing assessment and nursing plan of care. Frequency of assessment may be determined by institutional policy, patient condition, CMS requirements, and accreditation standards. See the NCQAC's Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for more information. The nurse should be aware that other laws and rules may apply such as facility laws and rules or the Centers for Medicare and Medicaid regulations.

The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse must consult with a physician. MSE requires a comprehensive assessment. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse's legal and individual scope of practice.

It may be within the scope of practice of the competent and appropriately trained registered nurse to perform a comprehensive on on-going assessment including pulmonary function tests (PFTs). The registered nurse must be competent to do these activities.  The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse legal and individual scope of practice.

The nursing laws and rules do prohibit the competent and appropriately trained registered nurse from performing a sports physical examination, making a nursing diagnosis and nursing interventions using the nursing process. Organizational policies may dictate who can perform a sports physical examination. Washington Interscholastic Activities Association (WIAA) or other voluntary nonprofit entity. The WAII Handbook identifies a Medical Doctor (MD), Doctor of Osteopathy (DO), Advanced Registered Nurse Practitioner, Physician's Assistant (PA), and Naturopathic Physician as a medical authority to perform a sports physical examination.

It is within the scope of an appropriately prepared and competent registered nurse to apply or remove an external or internal electronic fetal monitor under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse may apply the internal components if necessary. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to insert a FSE or IUPC under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to insert prostaglandin into the vagina for a cervical ripening or induction of labor with a viable fetus under the direction of an authorized provider, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to insert prostaglandin into the vagina for a chemical abortion under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to perform a fetal NST and amniotic fluid index level using ultrasound, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to perform a vaginal examination for pregnant or non-pregnant patients, following clinical practice standards. Obtaining cytologic specimens (e.g. a PAP smear or tests for sexually transmitted diseases) may require an order from an authorized provider in order for these test to be reimbursed. The registered nurse may perform cytologic tests following standing orders. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to perform a vaginal examination following, clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to perform ART procedures under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to perform sexual assault examinations and perform colposcopy to collect forensic evidence under the direction of an authorized provider, following clinical practice guidelines. Standing orders may be used. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission recommends the registered nurse receive training as a Sexual Assault Nurse Examiner (SANE).

It is within the scope of an appropriately prepared and competent registered nurse to provide epidural care under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. See the Nursing Care Quality Assurance Commission’s Administration of Sedating, Analgesic, and Anesthetic Agents Advisory Opinion for additional guidance and recommendations.

It is within the scope of an appropriately prepared and competent registered nurse to read a fetal monitor strip, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to remove a SAVI® applicator device under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

In most clinical situations, amniotomy should be primarily performed by authorized health care practitioners since complications may necessitate emergency medical intervention. While it is not routinely recommended that the registered nurse perform an amniotomy, it is within the scope of an appropriately prepared and competent registered nurse to perform this procedure under the direction of an authorized health care practitioner, following clinical practice standards. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of an appropriately prepared and competent registered nurse to follow standing orders to provide birth control or to screen for and treat sexually transmitted diseases.   The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations in using standing orders. The Public Health Nurses: Dispensing Medications/Devices for Prophylactic and Therapeutic Treatment of Communicable Diseases and Reproductive Health Advisory Opinion provides guidelines and recommendations. While this is specific to public health nurses, the general concepts apply to any setting. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

POLST is a set of medical orders, executed by an adult patient (or legal surrogate) and the patient's medical provider, to guide medical treatment based on the patient's current medical condition and goals. The POLST form is usually for persons with serious illness or frailty. The “rule of thumb” is to recommend POLST for patients if their provider would not be surprised if they die within a year.

The POLST concept was originally created to guide emergency medical services (EMS) personnel in emergency situations. EMS staff was not able to honor advance directives or family member instructions for no cardiopulmonary resuscitation (CPR), because EMS must follow medical orders. POLST was developed to allow EMS to honor patients' no-CPR decisions by turning them into medical orders.

POLST is intended to prevent unwanted or futile treatment, reduce patient and family suffering, and help ensure that individual's wishes regarding end-of-life care are honored. A POLST is valid in all care settings and is portable from one care setting to another. It does not replace advance directives or a durable power of attorney. It is valid with or without advance directives or durable power of attorney. In Washington, it is a bright green form (photocopies and faxes of signed POLST forms are also legal and valid) and should be located in a prominent, easily noticeable location in the home or bedside and in the medical record.

The POLST order allows patients to specify whether they desire CPR or whether they prefer to allow a natural death to occur if they are in cardiopulmonary arrest. It contains additional instructions as well, indicating if they have a pulse and/or are breathing, whether they want comfort measures only, specific limited additional interventions, or full treatment.

The POLST form is separated into four sections:

The patient (or surrogate decision-maker) and the health care provider should discuss information to assure the POLST reflects the patient's wishes, as expressed in an advance directive or through communications with family or others. The patient's most recent communications, made in the context of their current medical condition, are the most likely to reflect their current wishes. If the patient's wishes are not known, the POLST should direct care in the patient's best interest. RCW 7.70.065(1)(c).

No. Preparing and signing a POLST is always voluntary for patients. Care providers should follow a POLST as they would follow any other medical order. Chapter 43.70.480 RCW Emergency Medical Personnel - Futile Treatment and Natural Death Directives - Guidelines requires the Washington State Department of Health to adopt guidelines and protocols for how emergency medical personnel respond for the treatment of a person with a POLST.

Currently, only emergency medical responders are protected from legal liability when following the POLST orders. However, if a POLST order reflects a patient's wishes stated in an advance directive, the caregiver honoring those wishes would have legal protection under the Natural Death Act RCW 70.122. POLST is a medical order, and caregivers should follow it according to the standard of care. According to the Washington State POLST Task Force, no healthcare provider has reported being sued for following a POLST order since POLST was established in Washington State in 2000.

No. Preparing and signing a POLST is always voluntary. The Federal Patient Self-Determination Act (PSDA) and the Joint Commission require that health care facilities take steps to educate all adult patients on their right to accept or refuse medical care. Facilities must ask on admission whether a patient has made an advance directive, maintain policies and procedures on advance directives, and provide information to patients. The PDSA prohibits providers from conditioning care on whether or not an individual has an advance directive. The PDSA definition of advance directive has been interpreted to include a variety of advance planning documents, including POLST.

Not necessarily. The patient or resident's POLST is portable, and facilities should incorporate the patient's existing POLST into their records. Facilities may adopt policies requiring a provider with privileges to counter-sign the POLST.

A POLST should be reviewed upon admission. If a POLST has a recent date (within a year generally) and no major changes to the patient's condition have happen since the signing, it is acceptable to consider a confirmation of the POLST as meeting the requirement for inquiry of advance directives on admission.

There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required.

If a patient or resident has no POLST at the time of admission, suggest a care planning conference to evaluate whether POLST would be appropriate. These planning conferences should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers. A POLST should generally not be written as part of routine admission paperwork without medical professional involvement and extensive discussion.

Yes. The Natural Death Act RCW 70.122 allows health care facilities or personnel to refuse to participate in withholding or withdrawing life-sustaining treatment due to moral or ethical objections. Residents or patients must be informed of this policy or practice when the provider or facility becomes aware of the existence of a directive or POLST order they do not intend to honor. If an individual provider objects, the facility should try to make a willing staff member available to provide care according to the patient's POLST order. If the facility objects, it should cooperate with the patient or resident and family in finding and transferring the patient to another facility willing to honor the POLST order.

The POLST should be reviewed if the patient is transferred from one care setting or care level to another; if there is substantial change in the patient's health status; or if the patient's or decision-maker's treatment preferences change. There is a section on the POLST providers may initial to indicate that a review has been conducted and no changes are required. RNs and LPNs may explain or review the POLST form or existing POLST with the patient or surrogate.

Discussions about the appropriateness of the POLST or making significant changes to a POLST should include the patient's medical provider, the patient and surrogate decision-maker, and key family members. These discussions should include a review of the patient's medical history and recommendations from treating providers.

Discussions should consider whether the patient has advanced dementia, osteoporosis, bleeding disorder or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient. If the patient or surrogate and provider conclude this patient should not receive CPR even in case of choking or other accident, note “DNAR-No Exceptions” in Section A of the POLST. This note should be initialed by the provider authorized to sign the POLST.

A competent adult patient or the legal surrogate may always change their medical decisions and request alternative treatment. However, in an emergency situation, it may be difficult to determine whether or not the family member is the legal surrogate. Facilities should establish policies to manage legal risk in these situations.

The purpose of this advisory opinion is to provide guidance about POLST for advanced registered nurse practitioners (ARNPs), registered nurses (RNs), licensed practical nurses, LPNs), and nursing assistants (NAs). Advisory opinions do not have the force of law.

Yes. A licensed ARNP, physician or physician assistant may sign a POLST. The health care practitioner signing the form assumes full responsibility for obtaining informed consent from the patient or surrogate decision-maker. The form must also be signed by the patient or surrogate to be valid. Verbal orders are acceptable with a follow-up signature following facility policy.

The ARNP should periodically review the POLST instructions with the individual or family for any treatment preference changes and consistency with any advance directive, especially if there are substantial changes in the person's health status. The Washington State Medical Association provides many resources and references in helping individuals receive the end-of-life care they specify.

Yes. ARNPs, LPNs and RNs may follow valid POLST orders as they would follow any other medical orders, in any setting, based on their regulatory and individual scope of practice.

Delegation is not required for a nursing assistant to follow the CPR/DNAR POLST orders in Section A. Sections B and D of the POLST may require delegation of some tasks using the delegation process.

An ARNP, RN or LPN may pronounce death. ARNPs may file a death certification. It is not within the nursing assistant's scope of practice to pronounce death.

Yes. Nursing Assistants may follow the CPR/DNAR order in Section A of the POLST. Nursing assistants and other non-credentialed UAP may use nursing judgment in emergency situations. A patient without a heartbeat, even if death is expected, is in an emergency situation. A nursing assistant with appropriate training may assess the patient's vital signs and decide if a heartbeat is present. If there is no heartbeat, a nursing assistant may follow a patient's POLST order Section A to start CPR or to provide comfort measures and allow a natural death, depending on the patient's POLST.

Section B of a POLST include orders on medical interventions, including use of oxygen, suction, IV fluids, airway support and advanced interventions such as intubation, mechanical ventilation, and other intensive care-related procedures. Section D includes non-emergency treatment decisions including whether the patient should receive antibiotics, medically assisted nutrition and hydration, and dialysis. Some of these POLST orders may indicate medical interventions outside the scope of a nursing assistant. Specific activities may require delegation of certain medical interventions identified in the POLST sections B and D, depending on the task, equipment available, and competency of the nursing assistant.

The Washington State Department of Social and Health Services (DSHS) and POLST stakeholders have developed a short training video for home care aides and other bedside caregivers. The video includes instruction on how these staff should respond when they find a resident who is nonresponsive. This video will be part of a continuing education program which DSHS plans to approve in 2015.

Yes. Nursing assistants and other UAP may perform activities that require nursing judgment only in emergency situations. When a patient has no heartbeat, it is an emergency situation in which a nursing assistant may use nursing judgment to follow a POLST order to either perform CPR or to provide comfort care while allowing natural death to occur.

An individual is working under their nursing assistant credential only when being directed and supervised by a nurse. In situations where the nurse is not directing and supervising the care, the individual is not working under the nursing assistant credential. The employer or facility should have policies and procedures in place to address this situation.

In most circumstances, if a person's heartbeat stops during a witnessed choking incident or other accident, perform basic first aid measures per standard training. If the person has no pulse or becomes nonresponsive, begin CPR even if the POLST says “No CPR/allow natural death.” Continue CPR until licensed staff or emergency medical responders arrive.

However, some patients may want to refuse CPR under all circumstances including choking or accidents. This may be the medically appropriate decision for patients with advanced dementia at risk for aspiration, patients with osteoporosis, or other conditions and situations in which chest compressions or other CPR interventions may cause more harm than benefit to the patient.

Each patient's care plan should include details specifying if the POLST DNAR order applies in all circumstances. The POLST should include a note in Section A stating “DNAR-No Exceptions” initialed by an authorized provider. Bedside caregivers and supervisors should be familiar with this detail in the patient care plan and POLST.

If a patient's POLST order indicates no CPR, CPR should not be initiated. In the event that CPR is initiated for a person in violation of a POLST with a DNAR order, CPR should be discontinued if no pulse is detectable. This is an example of a situation where all health care providers caring for the patient must be aware of the medical orders for the patient. Facilities should establish policies to manage legal risk in such a situation.

Opioid antagonists reverse the effects of an opioid overdose. Naloxone (Narcan®) is the current standard of treatment for opioid overdose. The Food and Drug Administration (FDA) approves administration by intravenous, intramuscular, or subcutaneous routes; a hand-held auto-injector (Evzio®) for intramuscular or subcutaneous injection; and, in 2018, approved the first generic naloxone hydrochloride nasal spray. These are legend drugs, and not categorized as controlled substances. Naloxone has not been shown to produce tolerance or cause physical or psychological pain. It will produce withdrawal symptoms. Severity and duration of the withdrawal relate to the dose of naloxone and the degree and type of opioid dependency. See the Washington State Department of Health Overdose Education and Naloxone Distribution Webpage for more information.

RCW 69.41.095 does not require the Licensed Practical Nurse to carry an opioid antagonist, such as naloxone. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

The Registered Nurse may administer an opioid antagonist following a standing order from an authorized health care practitioner. This includes following the Washington State Department of Health Statewide Standing Order to Dispense Naloxone. The Registered Nurse should use the Scope of Practice Decision Tree to determine if the activity is within the nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides guidance and recommendations. For more information, go to the Washington State Department of Overdose Education and Naloxone Distribution Website.

RCW 69.41.095 allows the Registered Nurse, or any person, to carry and administer an opioid antagonist (such as naloxone) to a person suspected of experiencing an opioid overdose in any setting. The nurse must have a valid prescription, either in the nurse’s name, in the name of an entity, in the name of a person/patient, or through a standing order. The nurse may also get a prescription from a pharmacist with a Collaborative Drug Therapy Agreement (CDTA) or use the Washington State Department of Health Statewide Standing Order to Dispense Naloxone to get as a prescription. Anyone can take this standing order to a pharmacy to get a prescription. The nurse may also get a prescription in their own name from their health care practitioner. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

The Registered Nurse may dispense or distribute an opioid antagonist (such as naloxone) for a high-risk person, their family members, or friends following standing orders from an authorized health care practitioner. Any person or entity may lawfully possess, store, deliver, distribute, or administer an opioid overdose reversal medication with a prescription or standing order (RCW 69.41.095). The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

The Registered Nurse must be appropriately prepared and competent to perform the activity safely; just as in all care the nurse provides. The Washington state laws and rules do not require a specific training course or certification for naloxone. Stop Overdose.com offers education, resources, and technical assistance for individuals, professionals, and communities in Washington State who want to learn to prevent and respond to overdose and improve the health of people who use drugs. An employer or institution may have specific requirements for training or certification. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information and training resources, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

RCW 69.41.095 allows the Registered Nurse to have a prescription for an opioid antagonist (such as naloxone) in the nurse’s name to carry and administer an opioid antagonist in the non-work setting. Nurses may carry and administer an opioid antagonist in a suspected opioid overdose whether the person is a family member, friend, stranger, or a patient. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

The Registered Nurse may delegate administration of an intranasal opioid antagonist (such as naloxone) only in community-based (adult family homes, assisted living facilities, and community residential programs for people with developmental disabilities), in-home care settings, and K-12 public and private schools. It is not within the Registered Nurse’s scope of practice to delegate administration of an opioid antagonist by injection in any setting. RCW 69.41.095 provides an exception to the nursing delegation laws and rules and does not require nursing delegation for a nursing assistant-registered or nursing assistant-certified to administer naloxone. The Registered Nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. For more information, go to the Washington State Department of Health Overdose Education and Naloxone Distribution Website.

It is within the scope of an appropriately prepared and competent registered nurse to perform diagnostic imaging procedures under the direction of an authorized health care practitioner, following clinical practice standards. A prescription or order from an authorized provider is required. The prescription or order may be done following standing orders. Examples of diagnostic imaging procedures include:

The registered nurse may also perform interventional radiology procedures using minimally invasive therapies under imaging guidance. Common interventional radiology procedures include thrombolysis, needle biopsies, paracentesis, and thoracentesis. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice. See the Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion for additional information.

It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate the use of a peak flow meter following the student’s health care plan and the prescribed medication based on peak flow meter readings. The health care plan must include actions to take in case of an emergency situation. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.

It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate preparing a medication in a nebulizer chamber for inhalation via a mask or mouthpiece following the student’s health care plan and the prescribed medication. The order falls within the category of an oral medication whether or not the mask or spacer covers the mouth or the mouth and nose. Medications ordered intranasally are not included in this category. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within his or her scope of practice.

It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate following a range order of medications, such as administering one to two puffs, using an oral inhaler based on the prescription and specific criteria and identified in the health care plan. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within his or her scope of practice.

Non-credentialed assistive personnel may assist the student in identifying emergent or urgent asthma episodes in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements). This may include using the use of a peak flow meter and administration of quick-relief medications (such as inhaled bronchodilators). The nurse must include these activities in the emergency health care plan and medication prescription/orders, including the frequency that the medication can be given, from an authorized health care practitioner. The emergency health care plan must include actions to contact emergency services as appropriate.

The school nurse should use professional judgment and consider the following criteria to determine safe and appropriate delegation of asthma-related tasks to non-credentialed assistive personnel in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements):

RCW 28A.210 Common School Provisions: Health-Screening and Requirements does not allow an exception for a student to have a PDA to provide asthma-related tasks.

The following would be considered unsafe situations in which to delegate to non-credentialed assistive personnel asthma-related tasks in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements):

The school law does not provide an exception for the registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate administration of injectable glucagon to non-credentialed assistive personnel. RCW 28A.210.330 does allow a parent to authorize a parent-designated adult (PDA) to perform this task in this setting. The law allows a school staff person to volunteer to be a PDA or the parents can select a person not employed by the school to be the PDA. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.

The Food and Drug Administration (FDA) approved the first treatment for severe hypoglycemia that can be administered without an injection July 24, 2019. Baqsimi™ nasal powder. It is within the scope of the appropriately trained and competent registered nurse in the in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate this medication to non-credentialed assistive personnel. RCW 28A.210.260(5) requires a school nurse to administer intranasal medications when a licensed practical nurse or registered nurse is on the premises. RCW 28A.210.260(1)(5) allows delegation of an intranasal medication only if a licensed practical nurse or registered nurse is not on the premises to administer the medication. RCW 28A.210.330 allows a parent-designated adult (PDA) to administer an intranasal medication for diabetes. A school employee may volunteer to act as a PDA. After an intranasal spray (legend drug or controlled substance) is administered by non-credentialed assistive personnel, the employee must summon emergency medical assistance as soon as possible. The law does not stipulate which types of legend drugs or controlled substances administered intranasally, or specific conditions in which emergency medical assistance must be summoned. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.

The school law does not provide an exception for the registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate the task of performing a blood glucose capillary stick. RCW 28A.210.330 allows a parent to authorize a parent-designated adult (PDA) to perform this task. The law allows a school staff person to volunteer to be a PDA or the parents can select a person not employed by the school to be the PDA. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.

It is within the scope of an appropriately trained and competent registered nurse in the kindergarten through twelve grade, public and private school setting (RCW 28A.210 Common School Provisions: Health-Screening and Requirements) to delegate non-credentialed assistive personnel to obtain blood glucose readings from an implanted continuous monitoring device. The Nursing Care Quality Assurance Commission recommends the registered nurse use the Scope of Practice Decision Tree to determine if an activity is within their scope of practice.

The Nursing Care Quality Assurance Commission does not have authority to interpret the laws governing the provision of health care in K-12, public and private schools. Chapter 28A.210.383 RCW provides that the Office of the Superintendent of Public Instruction (OSPI) and school districts have the authority to develop anaphylactic policies for schools.

The law specifies that epinephrine autoinjectors may be prescribed to be maintained by schools for use when necessary. RCW 28A.210.383(2)(a). 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. RCW 28A.210.383(2)(b).  RCW 28A.210.383(4)(b) provides: “In the event a school nurse or other school employee administers epinephrine in substantial compliance with a student's prescription that has been prescribed by an authorized health care practitioner with prescriptive authority and written policies of the school district or private school, then the school employee, the school district or school of employment, and the members of the governing board and chief administrator are not liable in any criminal action or for civil damages as a result of administering epinephrine.” (RCW 28A.210.383).

RCW 28A.210.380 and RCW 28A.210.383 specifically require the use of an “autoinjector” to administer epinephrine. Symjepi® (https://www.symjepi.com/) is not classified as an EAI. This may apply to prescriptions for individual students as well as for the school supply.

RCW 28A.210.370 allows self-administration of medications, including epinephrine, if the student meets the requirements under the treatment plan for anaphylaxis, and has a prescription from their health care practitioner. This may include self-administering epinephrine using an EAI or a prefilled medication device if authorized in the prescription.

School registered nurses or licensed practical nurse (LPN) may provide telehealth services to students during the COVID-19 emergency within their legal scope of practice. The same standards apply regardless of whether the services are provided face-to-face or through telecommunication technology.

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 nurse must use nursing judgment and consider what aspects of the initial and ongoing assessment, supervision, and evaluation need to be done face-to-face. Telehealth may not be appropriate in some circumstances. The most important consideration is whether it is safe for the patient to perform the initial and ongoing assessment, evaluation, or supervision using telehealth services following the nursing and delegation laws and rules (RCW 18.79,  WAC 246-840, RCW 18.88A, WAC 246-841).

The nursing laws and rules do not prohibit the competent and appropriately trained licensed practical nurse from following a standing order or obtaining and carrying out a verbal order that is non-complex and routine. Standing orders and verbal orders may include medical orders or nursing orders. The licensed practical nurse may assist an authorized provider or registered nurse in carrying out a complex standing order or verbal order. The licensed practical nurse must be competent to carry specific steps identified in the standing order or verbal order. The licensed practical nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the licensed practical nurse's legal and individual scope of practice. The Nursing Care Quality Assurance Commission's Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

The nursing laws and rules do not explicitly prohibit the registered nurse from taking a verbal or telephone order. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

The laws and rules do not prohibit the registered nurse from accepting an order from an authorized medical provider through an unlicensed or licensed person. The registered nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. The implementing the order is required to see clarification of the order when the registered nurse believes, or has any reason to believe one, of these contraindications exists, and to take any other action necessary to assure the safety of the patient.

The laws and rules do not prohibit the registered nurse from calling in a medication order from an authorized medical provider. The registered nurse should use nursing judgment and determine whether additional verification or clarification is required. The laws and rules place accountability on the nurse who is implementing the order to implement or clarify that the order is accurate, valid, properly authorized, and is not harmful or potentially harmful to the patient, or is not contraindicated by documented information. Implementing the order is required to see clarification of the order when the registered believes or has any reason to believe one of these contraindications exists, and to take any other action necessary to assure the safety of the patient.

The nursing laws and rules do not prohibit the competent and appropriately trained registered nurse from working as a case manager or care coordinator. The registered nurse practices nursing care independently and do not require supervision or oversight from an authorized health care practitioner. The registered nurse must practice within his or her legal scope of practice.

The registered nurse licensed in another state would not be able to provide nursing services, including case management services to patients in Washington State without a Washington State nursing license.

Washington State does not have authority to define licensing requirements or scope of practice requirements in other states or countries. The registered nurse should contact that state to find out if the nurse needs a license in that state or country to provide nursing care.

The competent and appropriately trained registered nurse can perform triage activities within the nurse’s scope of practice or under the direction of an authorized health care practitioner – this may include following standing orders.  The registered nurse should use the Scope of Practice Decision Tree to determine if specific activities are within the registered nurse’s legal and individual scope of practice. The Nursing Care Quality Assurance Commission’s Standing Orders and Verbal Orders Advisory Opinion provides additional guidance and recommendations.

The EMTALA is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a MSE to each person presenting to the emergency department to determine if a medical emergency exists. MSE is beyond initial triage. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. The EMTALA Interpretive Guidelines identify the licensed registered nurse to be considered qualified medical personnel who can perform the EMTALA MSE and circumstances where the registered nurse must consult with a physician. MSE requires a comprehensive assessment. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the registered nurse’s legal and individual scope of practice.

All nurses in Washington State are required to complete a suicide prevention training course from an approved list. For more information, see the Washington State Department of Health’s Suicide Prevention Training for Health Professionals Approved Courses.

The LPN and RN may provide telehealth nursing services within their scope of practice to patients in Washington state. The nurse must be licensed in Washington, or be approved through the Emergency Volunteer Health Practitioners Program during the COVID-19 emergency.

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. The commission's advisory opinion on provides Standing Orders and Verbal Orders (PDF) additional information and guidance.

The Washington State Department of Health COVID-19 Guidance for Home Care, Home Health, and Hospice Agencies provides guidance and resources for health care professionals providing services in these settings.

The licensed practical nurse (LPN) or registered nurse (RN) should consider what they are trying to accomplish based on the patient needs and safety and within their scope of practice. It is up to the nurse, using nursing judgment, to determine which patients and services are appropriate for telehealth.

Washington state is not a member of the Nurse Licensure Compact (NLC) through the National Council of State Boards of Nursing (NCSBN) that allows the nurse to practice in member states with one state licensure in another state in the NLC. The nurse would need to contact the other state(s) to see if they can practice in their state with a Washington state license during the pandemic.

The U.S. Office of Health and Human Services-Office of Civil Rights Frequently Asked Questions on Telehealth and HIPAA provides information on waivers and exceptions and guidance during the COVID-19 emergency about HIPAA and telehealth services.

There are models of care in place that involve a medical team including nursing staff. Please refer to the Scope of Practice Decision Tree that will help you walk through your scope area.

Yes, licensed nurses (RN, LPN, or ARNP) in Washington state are required to take telemedicine training if the nurse provides telemedicine services. RCW 43.70.495 requires the nurse who provides clinical services through telemedicine independently or under the direction of an authorized health care practitioner to complete telemedicine training. “Telemedicine” as defined in RCW 70.41.020(13) means, “the delivery of health care services through the use of interactive audio and video technology, permitting real-time communication between the patient at the originating site and the provider, for the purpose of diagnosis, consultation, or treatment [but] does not include the use of audio-only telephone, facsimile, or email.”

The Washington State Telehealth Collaborative uses the following slightly different Medicaid definition of telemedicine in the training:

“Telemedicine is when a health care practitioner uses HIPAA-compliant, interactive, real-time audio and video telecommunications (including web-based applications) or store and forward technology to deliver covered services that are within his or her scope of practice to a client at a site other than the site where the provider is located.” WAC 182-531-1730(1). It does not include “the use of audio-only telephone, facsimile, or email.”

No, the telemedicine training requirement does not apply to audio-only telephone (telephone triage), facsimile, or email. However, the Nursing Care Quality Assurance Commission (NCQAC) recommends licensed nurses complete the telemedicine training if they provide services such as; telephone triage, remote patient monitoring (“RPM”, which enables recording and monitoring health data remotely), asynchronous telehealth (such as Store and Forward technology that allows patient data to be collected, stored, and later retrieved by another professional), Mobile Health (“mHealth,” using smart devices such as smartphones and smart wearables that allow continuous data collection about a person's behavior or condition) or other types of telehealth. The telemedicine training provides a valuable overview of the roles, responsibilities, liability, and legal requirements when providing telehealth services.

The law, RCW 43.70.495, requires the nurse to sign and retain an attestation of completion. The nurse does not need to send the attestation or documentation to the NCQAC unless requested.

The Nursing Care Quality Assurance Commission (NCQAC) recommends telemedicine training be completed as soon as possible as a demonstration of competency. The licensed nurse (RN, LPN, or ARNP) providing telemedicine clinical services licensed prior to January 1, 2021, will need to complete telemedicine training by December 31, 2021. The newly licensed RN, LPN, or ARNP or the RN, LPN, or ARNP licensed through the endorsement process who provides clinical services will need to meet the requirement one year after the initial license is issued. 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.

Telemedicine training taken prior to January 1, 2021, meets the requirement if it includes the content defined in RCW 43.70.495(2). The RN must be appropriately trained and competent to provide nursing telehealth services. To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.

To learn more about the different training options available and access additional resources, see the Washington State Telehealth Collaborative Training webpage. To complete the free and publicly available telemedicine training, see the Washington State Medical Professional Telemedicine Training website.

It is within the scope of practice of an appropriately prepared and competent registered nurse to perform bladder instillation therapy under the direction of an authorized health care practitioner, following clinical practice standards. Examples include instillation of dimethyl sulfoxide (DSMO), chemotherapy (e.g. Mitomycin C), and Bacillus Calmette-Guérin (immunotherapy) drugs. There must be an order from an authorized provider. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately prepared and competent registered nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, following clinical practice standards. The procedure may be performed in a home setting or an in-center setting. A prescription or order from an authorized provider is required. This includes preparing and monitoring the dialysis machine, accessing an arteriovenous (AV) fistula or graft or a central venous catheter, initiating or discontinuing hemodialysis, collecting specimens, catheter site care, and performing tubing or adaptor changes. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately prepared and competent registered nurse to perform peritoneal dialysis under the direction of an authorized health care practitioner, following clinical practice guidelines. A prescription or order from an authorized health care practitioner is required. This includes initiating or discontinuing therapy using pre-mixed medicated peritoneal dialysis bags, collecting specimens, catheter site care, and performing tubing or adaptor changes. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

It is within the scope of practice of an appropriately prepared and competent registered nurse to replace a suprapubic in an established tract under the direction of an authorized health care practitioner, following clinical practice standards. There must be an order from an authorized provider. In general, the first change in a non-established tract is usually done by an authorized provider. The registered nurse should use the Scope of Practice Decision Tree to determine if these activities are within the nurse’s legal and individual scope of practice.

Withholding medications, primarily anti-hypertensives, prior to dialysis is not uncommon. Due to the frequent tendency for patients to become hypotensive during treatment, and also the “pulling off” of medications during the dialysis procedure, nurses often withhold medications. It has often been considered a ‘community practice’ and has been taken for granted that medications could be withheld whether written orders by an authorized health care practitioner are obtained or not. Then the withheld medications are given post dialysis, usually with communication to the provider on the patient’s tolerance and outcomes for a successful dialysis and the provider’s determination of the next dialysis. It is not acceptable for the registered nurse to routinely withhold any medication prior to dialysis without an order from an authorized provider. This order may be written for an individual patient or through a standing order. The NCQAC’s Standing Orders and Verbal Orders Advisory Opinion and Verbal Orders provides additional guidance and recommendations.

For people with disabilities, Web documents in other formats are available on request. To submit a request, please contact us at civil.rights@doh.wa.gov.

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