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Nursing Assessments

Can RPNs conduct a nursing assessment and develop plans of care for patients, or can this only be done by a RN?

Regardless of a nurse’s category of registration, completing a nursing assessment is a foundational competency for all nurses. These are outlined in the Entry-to-Practice Competencies.

Nurses are expected to use their clinical judgement to determine whether they can safely and competently complete and assessment and provide care to a specific patient. Nurses are also expected to seek help, and to refrain from performing any activity that they are not competent to perform. Nurses may acquire specialized knowledge and this would influence which patients they are best suited to work with.

Employers and nurses have a shared responsibility to create environments that support quality practice. Nurses must ensure they are aware of their employer policies that support nursing assessment. If employer do not have policies that are in their patient’s best interest and safety, nurses should advocate for clear policies.

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Is a medical directive required for vital signs?  

Nurses can perform physical assessments such as vital signs without an authorizing mechanism (direct order or directive), as this is part of nursing assessment. Though nurses may not require an authorizing mechanism to perform this activity, employer policies may provide specific direction related to which category of nurse can perform this activity and how frequently.

Regardless of an employer’s policy, nurses are accountable for ensuring they use appropriate knowledge, skill and judgment when assessing and reassessing the health needs of patients. This includes having appropriate knowledge in the performance of clinical skills, such as assessing vital signs.

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Page last reviewed June 07, 2022