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Rx Med Staff, LLC

Dear Psych RN Applicant,

In order for Rx Med Staff, LLC to proceed with your employment process, the following documents MUST be completed prior to starting your assignment Please complete the attached documents and return asap via Fax (281) 596-7214 with copies of your current professional licenses and certifications If you have any questions about filling out the attached documents, please call our Recruiters any time at 1-832-527-0771 Our Recruiters will be happy to assist you with any of your questions or concerns.

Thank you for choosing Rx Med Staff, LLC as your healthcare career Agency!

Sincerely, Daniel Garza RN,BSN Administrator


Rx Med Staff, LLC

Forms Checklist

Please note that all the below forms MUST be completed and returned to us prior to your first day of employment

Completed Employment Application ____ 5 Year Employment Profile ____ Current Resume ____ Scheduling Questionnaire ________ 3 Recent Employment References ____ Proficiency Skills Checklist ____ Authorization to Drug Screen Form____ Background Check Authorization Form ____ Medical Information Release Form ____ Physician Statement ____ Annual Employee Health Form ____ Employee Evaluation Form ____ Worker’s Compensation Form ____ Employment Guidelines ____ Timesheet Policy Form ____ I-9 ____ W-4 ____ Direct Deposit Form with Cancelled Check ____ All Copies Need to be made one per page (not all on one page) Copy of Driver’s License ____ Copy of Social Security ____ Copy of BLS____ Copy of ACLS____ Copy of other Applicable Certification ____ Copy of Professional License ____ Benefits Option Form ____


Rx Med Staff, LLC

Employment Guidelines 1 Rx Med Staff, LLC is dedicated to providing quality healthcare professionals Always be on time and look your very best Adhere to the dress code and follow all the rules and regulations of the hospital 2 ASSIGNMENTS are offered on a first come first serve basis We inform the hospital of your availability, shift preferences, and specialty While the initial hours and days of work are set forth and explained in the interview, these are not guaranteed during your employment and you may be asked to work other shifts, hours, or areas as organizational needs require 3 SALARY will be discussed when the position is offered Your salary is confidential and should not be discussed with others except your recruiter Failure to adhere to this policy could result in termination Employees receive their paychecks weekly Federal withholding taxes and FICA are with held from your check in accordance with Federal laws State taxes are withheld accordingly Rx Med Staff, LLC will observe the same holidays as the hospital where you are assigned Time and one half is paid for hours worked on holidays, and overtime over 40 hours per week Time sheets will be provided for you. You are responsible for faxing or calling in your time on Monday mornings before 11:00 am No payroll checks can be issued until time sheets are in the office and, therefore, it is suggested that all employees confirm the receipt of faxed time sheets via telephone 4 INSURANCE is not provided by the hospital Rx Med Staff, LLC provides insurance benefit options for its employees As a licensed professional, malpractice insurance is of the utmost importance and is recommended 5 CANCELLATION of a shift must be 4 hours prior to the beginning of the shift and must be made up in order to receive bonuses 6 LICENSURE must be verified and on file prior to your employment with Rx Med Staff, LLC 7 EMPLOYEES are hired on the basis of character, references, qualifications and their ability to perform their duties competently Employees are required to have at least one-year current hospital experience, and one year in specialty area 8 Rx Med Staff, LLC is an equal opportunity employer Employees are hired and promoted without regard to race, color, creed, national origin, age or gender 9 APPLICATION Your application for employment and all other forms completed, including W-4 and I-9 forms, become a part of your permanent record Any willful misrepresentation of facts or misstatements made on these records will be grounds for dismissal 10 PERFORMANCE EVALUATIONS continuing education credits and certifications will also be maintained at all times in your file It is your responsibility to notify our office of any changes in your tax status and to supply us with additional certifications that you wish added to your file Failure to adhere to the rules and regulations of this company and the facility where assigned will not be tolerated Disciplinary action ranging from written warning to suspension without pay and termination will be taken Any disciplinary action will become a permanent part of your file All accidents or injuries involving a patient or employee must be reported to your supervisor and Rx Med Staff, LLC immediately Contact Rx Med Staff, LLC immediately if a question of liability arises 11 TERM OF EMPLOYMENT - Your employment with Rx Med Staff, LLC is at will and for no definite period This means that, just as you can terminate your employment with Rx Med Staff, LLC at any time and for any reason, with or without notice or cause, Rx Med Staff, LLC retains a similar right By signing these guidelines, you understand that no guarantee of continued employment has been made to you


Rx Med Staff, LLC

12. Rx Med Staff, LLC has a zero tolerance of sexual harassment. Please contact Rx Med Staff, LLC immediately or the human resources director at the healthcare facility where you are assigned if you have been sexually harassed or subjected to any form of sexually inappropriate behavior PLEASE READ CAREFULLY BEFORE SIGNING THESE GUIDELINES: I understand and acknowledge that no guaranteed or fixed employment term has been offered to me I understand that if I do not cover any shifts for a period of 30 days I will be terminated from employment and will not be eligible for unemployment compensation Rehiring will be based on past work record I authorize Rx Med Staff, LLC to investigate all statements in my application and to secure any necessary information from all my employers, references, and academic institutions I hereby release all of those employers, references, academic institutions, and Rx Med Staff, LLC from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and suitability for employment with Rx Med Staff, LLC I authorize Rx Med Staff, LLC to do a police background check if a hospital requires this type of information In the event of employment or an offer of employment, I authorize any physician or hospital to release any information which may be necessary to determine my ability to perform the essential functions of the job for which I am hired or being considered I hereby agree to submit to any lawful drug, alcohol or other testing that may be required as a condition of employment or continued employment and understand that refusal to submit to such testing during the course of my employment may result in termination I agree and understand that any offer of employment I may receive is contingent upon my successful completion of the Rx Med Staff, LLC pre-employment screening process including any physical examination that may be required I have read and I agree to meet Rx Med Staff, LLC minimum requirements of the position for which I am being hired, as described in the “Job Profile� I will comply with all rules, regulations, and policies of Rx Med Staff, LLC I understand that nothing in this employment application, or any communications with Rx Med Staff, LLC employees, executives or a representative intended to create an employee contract between Rx Med Staff, LLC and I also understand that Rx Med Staff, LLC has the right to modify its policies without giving me any notice of changes No promises regarding employment have been made to me, and I understand that no such promises are guaranteed by Rx Med Staff, LLC unless made in writing and signed by an authorized representative of Rx Med Staff, LLC. I certify that I have read, understand and agree to the above conditions of employment _______________________________________ _______________________ Employee Signature Date


Rx Med Staff, LLC

Application Name: _______________________________________________________________________________________ Last

First

Middle initial

Current address: _______________________________________________________________________________ Number

Street

City

State

Zip

Phone: ( _____ ) __________________________ __________________________ __________________________ At this location until

Best time/day to reach you

Permanent address: _____________________________________________________________________________ Number

Street

City

State

Zip

Phone: ( _____ ) __________________________ __________________________ __________________________ Best time/day to reach you

Social Security Number

Date available to travel: _________________________________________________________________________ Please select one: RN Nurse Midwife CST OTHER_______________________________ Specialty: _____________________________________________________________________________________ LICENSURE State where originally licensed (Please include a photocopy.) State: License #:

State: License #: Expiration Date:

Expiration Date:

Other license list: state:____ #__________; state:____ #____________ Has your nursing license ever been investigated or suspended? _____Yes _____ No If yes, attach separate sheet with explanation Have you ever been convicted of a crime other than a minor traffic violation? _____Yes _____No If yes, attach separate sheet with explanation

Can you submit verification of your legal right to work in the U S ? _____Yes _____No How did you hear of RX Med Staff? ____________________ If Nursing Journal please write in name ____________________________________ If referred by RN or CST write their name so they get bonus ____________________________________________ BLS is required of all nurses Please enclose copy BLS Expiration Date________________ ACLS Expiration Date________________ PALS Expiration Date__________________ Other _________________ Recruiter’s Initials;________


Rx Med Staff, LLC

Education College Nursing School Other University/College

Name and Location of School

Year Graduated

Diplomas, Degrees/Certificates Received


Rx Med Staff, LLC

Recruiter’s Initials:___________ EMPLOYMENT PROFILE Applicant’s Name: ________________________________________________ Please indicate all employment, beginning with your most recent employer Document reasons for periods of unemployment Are you employed now? _____Yes _____No

If working through an agency, please indicate the specific hospital

If so, may we contact your present employer? _____Yes _____No

EMPLOYMENT PROFILE PLEASE LIST YOUR EMPLOYERS BY THE MOST CURRENT EMPLOYER FIRST Name of employer ______________________________________________________________ Address ____________________________ City ___________State _________ Zip _______ Date of Hire _________to_____________ Job title _________________________ Name of supervisor __________________________Title ______________________________ Description of work _____________________________________________________________ _____________________________________________________________________________ Reason for leaving ______________________________________________________________ _____________________________________________________________________________ ***************************************************************************** Name of employer ______________________________________________________________ Address ____________________________ City ___________State _________ Zip _______ Date of Hire _________to_____________ Job title _________________________ Name of supervisor __________________________Title ______________________________ Description of work _____________________________________________________________ _____________________________________________________________________________ Reason for leaving ______________________________________________________________ _____________________________________________________________________________ ***************************************************************************** Name of employer ______________________________________________________________ Address ____________________________ City ___________State _________ Zip __________ Date of Hire _________to_____________ Job title _________________________ Name of supervisor __________________________Title ______________________________ Description of work _____________________________________________________________ Reason for leaving ______________________________________________________________ ***************************************************************************** Name of employer ______________________________________________________________ Address ____________________________ City ___________State _________ Zip ________ Date of Hire _________to_____________ Job title _________________________ Name of supervisor __________________________Title ______________________________ Description of work ____________________________________________________________________ ____________________________________________________________________ Reason for leaving _______________________________________________________________


Rx Med Staff, LLC

REFERENCES

1

Reference name:

Comments:

Address: City:

State:

Telephone Number:

Zip:

_____

Ext :

2 Reference name:

Comments:

Address: City:

State:

Zip:

_____

Ext :

Telephone Number: 3 Reference name:

Comments:

Address: City: Telephone Number:

State:

Zip:

_____

Ext :

************************************************************************ I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and pertinent information concerning they may have, personal or otherwise and release the company from all liability for any damage that may result from utilization of such information Signature _______________________________________ Date ___________


Rx Med Staff, LLC

PHYSICAL EXAM (To be completed by physician) If you develop any of the symptoms listed above, please contact your physician and us immediately A chest x-ray must be performed prior to working again

Please check the following statements that apply to you:

Varicella History ______ I have had Chicken Pox ______ I have NEVER had Chicken Pox ______ I have not had Chicken Pox, but I may have cared for a person with Chicken Pox ______ I have received the Varicella vaccine on date___________________

Hepatitis B History ______I have been vaccinated for Hepatitis B and finished the series of 3 injections on date _________________ ______I have started the series of 3 Hepatitis B injections, but did not finish the series ______I have had Hepatitis B in the past ______I refuse the Hepatitis B Vaccination Series

Glove Sensitivity _____I have NO skin problems wearing gloves while performing my job duties _____I have skin problems wearing gloves while performing my job duties

Please explain condition ________________________________________________________________________________

Health Questionnaire: Have you seen a physician for any illness or injury in the last 12 months? Yes No If yes, please explain ___________________________________________________________________________________


Rx Med Staff, LLC

Have you had any x-rays taken in the last 12 months? Yes No Have you been hospitalized in the last 12 months? Yes No If yes, please explain ___________________________________________________________________________________ Have you ever suffered a work related injury? Yes No If yes, please explain ___________________________________________________________________________________ Have you ever filed for and/or received Worker��€™s Compensation benefits? Yes No If yes, please explain ___________________________________________________________________________________

Have you ever suffered an illness or injury other than at work where you were Yes No off from work for more than one week? If yes, please explain ___________________________________________________________________________________ Have you ever been injured in a car accident? Yes No If yes, please explain ___________________________________________________________________________________ Please check any of the following activities for which you currently have or have had a restriction performing:

Lifting ____________________ Standing ______________________ Squatting__________________ Carrying __________________ Walking ______________________ Crawling __________________ Sitting ____________________ Bending ______________________ Climbing __________________

Give a brief description of any restrictions checked above _____________________________________________________________________________________ _____________________________________________________________________________________


Rx Med Staff, LLC

N M STAT ANN 52-1-28 3 (1991 W C ACT) False statements and/or representations made on this questionnaire may cause forfeiture of worker’s compensation benefits under the provision of 52-1-28 3 of the 1991 Worker’s Compensation Act provided, the worker knowingly and willfully concealed information or made a false representation of his/her medical condition Please note we require copies of all immunizations including TB, HEP B, & MMR (Measles, Mumps & Rubella) for our files

This information listed above is true and correct to the best of my knowledge, and I understood all of the questions listed above

_______________________________________ Employee Signature

date: ____________________


Rx Med Staff, LLC

Physician Statement

This form is to be completed by your Examining Physician:

Employee Name: ______________________________ Date _____________________________ SS#______________ Date of Birth Age _____________

Health History: Check off which conditions apply Yes No Yes No Asthma _____ _____

Nervous Stomach _____ _____

Kidney _____ _____

Rheumatic Fever _____ _____

Tuberculosis _____ _____ Muscular disease _____ _____ Syphilis ____ _____

Psychiatric disease _____ _____

Gonorrhea ____ _____

Cardiovascular disease _____ _____

Diabetes _____ _____

Gastrointestinal ulcer _____ _____

Head or spinal injuries _____ _____ Seizures, fits, convulsions _____ _____ Extensive confinement _____ _____ Any nervous disorder _____ _____ Permanent defect ____ _____ from illness, _____ _____

If yes to any of the above conditions, please explain________________________________________________

Temperature ______ Pulse ______ Respiration _______ Blood Pressure _______ Height ______ft ______ in Weight lbs Eyes Globe NL AB Pupils NL AB Nose NL AB

Nose NL AB Mouth Teeth NL AB Throat NL AB Pupils NL AB

Ears Canal Clear NL AB TM Visualized NL AB


Rx Med Staff, LLC

Skin NL AB

Chest Wall NL AB

Neck NL AB

Lungs NL AB

Thyroid NL AB

Upper Extremity NL AB Hands/Fingers NL AB Legs NL AB Knees NL AB Feet/ankles NL AB

Heart Rhythm NL AB Auscultation NL AB Abdomen NL AB Abd Surg Scar NL AB

Varicosities NL AB Up Ext strength NL AB Up Ext ROM NL AB Low Ext strength NL AB

Hernia Umbilical N Y Inguinal N Y Femoral N Y Varicocele N Y

Back/spine ROM NL AB Back surg Scar N Y

Reflexes Pupillary Rt NL AB Lt NL AB Knee Rt NL AB Lt NL AB

Sensory Examination: Up Ext Rt NL AB Lt NL AB Low Ext Rt NL AB Lt NL AB

The person named above has been examined by me and found to be in good physical and mental health, free from communicable disease and able to function as a nurse at full capacity The above information is true to the best of my knowledge I hereby authorize ___________________________________ and its licensed physicians to release this Physical Examination Report to ____________________________________________

Examining Physician______________________________________Date_____________________


Rx Med Staff, LLC

Worker’s Compensation Policy

Rx Med Staff, LLC carries worker’s compensation policy to protect all employees in the event of injury arising out of and in the course of their employment All injuries will be reported within 24 hours to the immediate supervisor The employee may be subject to a statutory penalty for late reporting An incident report must be filed at the time of injury SAFETY RULES

1 The use of alcohol during business hours is strictly prohibited 2 The use of illegal drugs is strictly prohibited 3 All employees are required to follow proper body mechanics to lift patients 4 Operate only the equipment that you have been authorized or directed by your supervisor 5 Report all faulty equipment Do not try to repair faulty equipment 6 Report any and all unsafe conditions Do not try to correct them unless authorized or directed by your Supervisor 7 Wash hands often and thoroughly with soap 8 Wear proper equipment such as gloves, goggles, etc Always follow universal precautions 9 Clean walkways of spills, debris, etc that could cause falls 10 Follow proper procedures to dispose of all hypodermic needles No recapping needles 11 Wear low-heeled shoes with rubber soles and heels 12 Mandatory safety meeting annually is required, including Fire & Safety, Needle stick prevention, and hazardous communication, Infection control/Aids/Hepatitis/ Body mechanics 13 Follow all hospital safety policy and procedures

I have read and received a copy of the safety rules and procedures of Rx Med Staff, LLC on this date below I understand that it is my responsibility to contact the Office with any questions that I may have I have read the policy and will abide by the governing

_______________________________ _______________________________ Employee Signature

Date


Rx Med Staff, LLC

HEPATITIS B VACCINE CONSENT / DECLINATION I

Acceptance of Hepatitis B Vaccine I acknowledge that I am at risk of exposure or have been unknowingly exposed to the Hepatitis B virus as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis B Vaccine at no cost to myself It is my decision to request that I receive the Hepatitis B Vaccine Employee

II

Date

Declination of Hepatitis B Vaccine I am refusing the Hepatitis B Vaccine and hold harmless the Agency I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection I have been given the opportunity to be vaccinated with Hepatitis B Vaccination However, I decline Hepatitis B Vaccination at this time I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and want to be vaccinated with the Hepatitis B Vaccine, I may receive the Hepatitis B Vaccination Series at no charge to me Employee

III

Date

Documentation of Hepatitis B Vaccine Series I have received the complete Hepatitis B Vaccine Series, and have attached to this form the documentation, which proves my receipt of the HBV Series Provide written proof of immunity (attach supportive documentation) Provide written proof of previous vaccination (attach supportive documentation) Provide written proof of medical contraindication (attach supportive documentation) Employee

Date


Rx Med Staff, LLC

The above named patient has been examined by me and found to be in good physical and mental health, free of communicable disease and able to perform the functions of the position without restrictions Physician Signature: _______________________________________________________ Physician’s Name: ______________________________ License # _________________ (Please print)

Address: ________________________________________________________________ City: ___________________________ State: __________________ Zip: ____________ Lab Results Must Be Attached


Rx Med Staff, LLC

Authorization to Drug Screen I ,____________________________________________________ fully understand that as a condition of my Employment with Rx Med Staff, LLC I agree Rx Med Staff, LLC requires that all employees have a drug screen of hair, urine, or blood prior to employment, and at any time during my employment if suspicion, per applicable policy(s) authorizes I understand that I shall be tested for the following: Amphetamines, PCP, TCH, Opiates, Cocaine, Barbiturates, Benzodiazepines, Methadone, Methaqualone, Propoxyphene and Alcohol. I fully understand that my refusal to submit to and fully cooperate in this drug screen as set forth by Rx Med Staff, LLC policy, will constitute cause for disciplinary action including termination of employment, or withdrawal of an offer of employment. Please list any medication you have taken in the last 3 months Include any over-the-counter medications: I understand that I may be asked to provide documentation from a physician for prescribed medications I understand that misrepresentation of or omission of any information on this consent will be grounds for termination or refusal to hire I give Rx Med Staff, LLC permission to release this information to all facilities in which I may be working and to the State Board of Nursing I hold Rx Med Staff, LLC harmless for any resulting effects from release of this information I consent to have my urine tested for drugs _______________________________________ Employee Signature

____________________ Date


Rx Med Staff, LLC

Medical & Information Release Form

I, _________________________________________ hereby release my former employer(s) from any and all liability that may be related to my former employer(s) release of the information requested below

I also further consent my former employer to release the information listed below to Rx Med Staff, LLC

_________________________________________________________________________________

__________________________________ _______________________________ Employee Signature

Date


Rx Med Staff, LLC

Annual Employee Health & Pre-Employment Screen Form

Employee Name:___________________________________ SSN#:_________________________ Rx Med Staff, LLC requires an annual tuberculosis test for each employee The tuberculin test is used to detect individuals with active or latent tuberculosis infections A small amount of protein derived from the tuberculosis organism is injected into the skin The test is read 48-72 hours later Patients with active disease may not have any symptoms, but may be infectious to others Active tuberculosis can be effectively treated It is also important to identify individuals with latent infections Preventive treatment can be given which will prevent the development of active disease and the subsequent infection of others Step I If you have had a positive PPD in the past, or if you are allergic to purified derivative protein or eggs, go to Step II If not, please complete Step I and provide a copy of your current TB test

Step II Since you have had a positive/sensitive PPD, you are required to have a chest x-ray Chest x-rays must be completed every 5 years and a copy must be maintained in your file Date of last x-ray: _________________________ Please provide copy of x-ray results Please read and put a checkmark in the correct space if you are experiencing any of the following symptoms or if any of the following apply to you: Yes No 1 Unplanned/Unexplained loss of weight (>10% of body weight) ____ ____ 2 Night sweats ____ ____ 3 Fever lasting several weeks ____ ____ 4 Frequent coughing in the absence of a cold or flu ____ ____ 5 Coughing blood-streaked sputum ____ ____ 6 Unusual tiredness or weakness lasting weeks ____ ____ 7 Pain in chest when taking a breath ____ ____ 8 Have you been recently diagnosed with diabetes, silicosis, HIV disease, rental disease, liver disease? ____ ____ 9 Have you been recently been exposed to a family member or others with active TB? ____ ____ If you checked YES to any of the above question, please explain condition and if you are being treated by a physician:


Rx Med Staff, LLC

Annual Employee Health Pre-Employment Screen Form - Page 2

If you develop any of the symptoms listed above, please contact your physician and us immediately A chest x-ray must be performed prior to working again Please check the following statements that apply to you: Varicella History ______ I have had Chicken Pox ______ I have NEVER had Chicken Pox ______ I have not had Chicken Pox, but I may have cared for a person with Chicken Pox ______ I have received the Varicella vaccine on date___________________ Hepatitis B History ______I have been vaccinated for Hepatitis B and finished the series of 3 injections on date _________________ ______I have started the series of 3 Hepatitis B injections, but did not finish the series ______I have had Hepatitis B in the past ______I refuse the Hepatitis B Vaccination Series Glove Sensitivity _____I have NO skin problems wearing gloves while performing my job duties _____I have skin problems wearing gloves while performing my job duties Please explain condition ________________________________________________________________________________ Health Questionnaire: Have you seen a physician for any illness or injury in the last 12 months? Yes /No If yes, please explain ___________________________________________________________________________________ Have you had any x-rays taken in the last 12 months? Yes/ No Have you been hospitalized in the last 12 months? Yes /No If yes, please explain ___________________________________________________________________________________ Have you ever suffered a work related injury? Yes /No If yes, please explain ___________________________________________________________________________________ Have you ever filed for and/or received Worker’s Compensation benefits? Yes /No If yes, please explain ___________________________________________________________________________________ Have you ever suffered an illness or injury other than at work where you were Yes /No off from work for more than one week? If yes, please explain ___________________________________________________________________________________ Have you ever been injured in a car accident? Yes /No If yes, please explain ___________________________________________________________________________________


Rx Med Staff, LLC

Annual Employee Health Pre-Employment Screen Form - Page 3

Please check any of the following activities for which you currently have or have had a restriction performing: Lifting __________________ Standing ____________________ Squatting__________________ Carrying __________________ Walking _____________________ Crawling __________________ Sitting ___________________ Bending _____________________ Climbing __________________ Give a brief description of any restrictions checked above _____________________________________________________________________________________ _____________________________________________________________________________________ N M STAT ANN 52-1-28 3 (1991 W C ACT) False statements and/or representations made on this questionnaire may cause forfeiture of worker’s compensation benefits under the provision of 52-1-28 3 of the 1991 Worker’s Compensation Act provided, the worker knowingly and willfully concealed information or made a false representation of his/her medical condition Please note we require copies of all immunizations including TB, HEP B, & MMR (Measles, Mumps & Rubella) for our files This information listed above is true and correct to the best of my knowledge, and I understood all of the questions listed above

_______________________________________ ____________________ Employee Signature

Date


Rx Med Staff, LLC

Employee Evaluation Policy

In order for us to ensure that all current and prospective employees maintain a high level of skills and professionalism, we adhere to the following Employee Evaluation Policy:

Prior to employment, we send out three employee evaluation letters to previous employers; prospective employees are evaluated according to the following criteria:

• • • • • • • • • • •

Clinical Knowledge Judgment Quality of work Direction, Cooperation & Acceptance Communication Skills Abiding by Facility Policy & Procedures Initiative Professional Appearance Punctuality & Dependability Probation Period is Days Ability to handle routine & Emergency Situations

Registered Nurses and Licensed Practical/Vocational Nurses are required to have NLN Pharmacology test completed and passed with a rate of 80% or higher After the nurse is responsible for having the charge nurse complete an evaluation form and return it to Rx Med Staff, LLC with time sheet One evaluation is due in the first week of employment and then one every month thereafter Should the evaluations not be completed and receive an above average to superior in rating each month (no later than the last pay period of each month), bonuses will not be paid at the end of the contract If the first Agency Nurse Evaluation conveys a below average level of expertise or pattern of behavior, the employee is issued a verbal warning The second Agency Nurse Evaluation characterizing employee’s performance as below average leads to a written warning If the third Agency Nurse Evaluation shows that the employee’s performance is below average, the employee is subject to termination The nurse will turn in the evaluation form once a month to the charge nurse and request that it be faxed to Rx Med Staff, LLC The charge nurse signature and printed name with department and phone number should be clearly legible

_______________________________ Employee Signature

_______________________________ Date


Rx Med Staff, LLC

Employee Evaluation Form

Employee Name _______________________________ Date of Evaluation _____________________

Facility ______________________________________ Unit__________________________________

Attention Charge Nurse please evaluate our Rx Med Staff, LLC employee Please include all information pertinent to our employee Please fax completed form to our office (832) 527-0771, or return by mail Attention Rx Med Staff, LLC Employees! This evaluation is to be completed by the charge nurse your first week & once a month thereafter Please check (v) which performance applies Job Performance of Applicant: Above Below 1=Superior/ 2=Above Average/3=Average/ 4=Unacceptable

• • • • • • • • • • •

Clinical Knowledge _______ Judgment _______ Quality of Work _______ Quality of Documentation _______ Accepts direction/cooperation _______ Abides by Facility policy and procedures _______ Communication Skills _______ Initiative _______ Handles routine and emergency situations _______ Punctually and Dependability _______ Professional Appearance _______

Comments on Employee: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ __________________________ ____________________ Evaluator’s Signature Title

__________________ Date Signed


Rx Med Staff, LLC

Employee Benefits Options

Please complete the following: Name: _______________________________ SS #: __________________________ Marital Status: ________________________ Phone: _________________________ Date of Hire: __________________________ Benefits Eligibility Date: ___________ Mailing Address (Benefits material will be sent to this address): _________________________________________________________________________________ _________________________________________________________________________________ *** (Please Initial next to your preference) *** Healthcare Benefits ______ No, I do not want healthcare benefits ______ Yes, I am interested in healthcare benefits SIMPLE IRA (Individual Retirement Fund) ______ No, I do not want to participate in the SIMPLE IRA retirement plan ______ Yes, I am interested in participating in the SIMPLE IRA retirement plan Per Diem Employees ______ I acknowledge that I have chosen to work on a per diem basis and that I will not be eligible for benefits that are supplemented by Rx Med Staff, LLC My negotiated hourly pay will be my full and complete compensation I have read and understand the benefits options as stated above _______________________________ _______________________________ Employee Signature Date


Time Sheet Policy A rate agreement or contract signed by you and recruiter should be in your file! All timesheets are due in the office every Monday by 08:00 a.m.,Central Standard Time. You may fax your timesheets to (281)-596-7214. Furthermore, it is recommended that you confirm that we have received your timesheet. Any timesheets that are not received by Monday at 08:00 a.m. will be paid on the following payday. If you do fax in your timesheets, the originals must be received in the office by Thursday at noon. We cannot bill the facilities without the original timesheets. It is important that you submit your timesheets weekly, as we bill the facilities on a weekly basis. Do not turn in timesheets for more than one week at a time. Payday is every Friday. Rx Med Staff, LLC pay period is Sunday thru Saturday, paying the following Friday Please check with the office for the different pay periods. Also if you are on a “Travel Contract� your schedule must be faxed or called in as soon as it is given to you. Please provide the following in order to be paid accurately and in a timely manner. Name Facility Where You Worked Date Department (example: ER, OR, ICU, TELE, CCU) Time In/ Time Out/ Total Hours Less Meals (Note: If you do not take a meal break, you must have the shift supervisor initial the less meals space on your timesheet, otherwise a .5 break will be deducted from your hours for that shift). OT Hours/Mileage/On Call Hours/ Call Back Hours/ Charge Nurse Hours/Supervisor Initials Your signature Supervisor Signature(Required to Have Paycheck Processed!) If you are on contract with a facility for a certain amount of hours per week and you work less than that amount of hours, please be sure and indicate on your timesheet if your shift was canceled by the facility, or if you canceled a shift. This information will help the payroll department pay you accurately, as well as bill the facility accurately. If you have pre-scheduled a shift with a facility, please be sure and inform your staffing coordinator of the shift at least one day prior to commencing the shift, so we can confirm with the facility, and put you on the schedule. Submit the white copy of your timesheet to your local office, leave the pink copy with the charge nurse, and retain the yellow copy for your records. If you believe that there is an error with your paycheck, please contact the payroll department immediately. If you would like direct deposit, complete a direct deposit form, which may be obtained at your local office. In order to keep payroll processed on a weekly basis, it is imperative that everyone comply with the timesheet policy. No exceptions will be made. The payroll department will not be able to process checks if the timesheet policy is not followed. I have read and understand the timesheet policy as stated above. ___________________________________ ___________________ Employee Signature Date


Rx Med Staff, LLC

ACKNOWLEDGMENT OF OSHA TRAINING

I, _________________________________ have been presented with training on occupational exposure to blood borne pathogens, hazardous chemicals procedures, advance directive, lifting safely to protect your back, general hazard prevention, fire safety training, preventing the spread of infection, universal/BSI precautions, age specific, abuse and neglect, and restraint policies by Rx Med Staff, LLC on this date _____/_____/_____ My signature constitutes that I understand and I will comply with these and all standards set forth by OSHA and comply with each of the facilities Exposure Control Plans I will obtain any additional information I need to safely work with hazardous chemicals in the work place By signing this form I assume the responsibility of maintaining these standards If I have any questions or require any additional information, I will notify Rx Med Staff, LLC

____________________________ ______________ Employee Signature Date


Rx Med Staff, LLC

OSHA TRAINING

ADVANCE DIRECTIVES The Federal Patient Self-Determination Act requires that hospitals maintain policies for providing information to all adult individuals, which presumably includes competent as well as incompetent patients, but clearly does not include minors If a patient is incompetent, the hospital’s procedures should provide for documentation in the patient’s records that information was provided to the patient, but in the opinion of a physician, the patient was not competent to understand the information Information must be provided at all times of inpatient admission This does not apply to outpatients SOME MEANINGFUL DEFINITIONS ADVANCE DIRECTIVE – A Directive to Physicians or a Durable Power of Attorney for Health Care Also know as Living Will DIRECTIVE TO PHYSICIAN – An oral or written instruction under the Natural Death Act to withhold or withdraw lifesustaining procedures in the event of a terminal condition DURABLE POWER OF ATTORNEY FOR HEALTH CARE – A Document delegating to an agent the authority to make health decisions on behalf of a principal as provided be the Durable Power of Attorney for Health Care Act TERMINAL CONDITION – An incurable or irreversible condition caused by injury disease or illness, which, without the application of life sustaining procedures, would, within reasonable medical judgment, produce death, and where the application of life-sustaining procedure serves only to postpone the moment of death QUALIFIED PATIENT – A qualified patient is a patient who suffers from a “terminal condition” that has been diagnosed and certified in writing by the attending physician and one other physician who have personally examined the patient LIFE SUSTAINING PROCEDURE – A medical procedure or intervention which utilizes mechanical or other artificial means to sustain, restore or supplant a vital function which would serve artificially only to prolong the moment of death and where, in the judgment of the attending physician, noted in the qualified patient’s medical records, death is imminent whether or not such procedures are utilized or will result within a relatively short time without application of such procedures It does not include medication or medical procedures deemed necessary to provide comfort, care or alleviate pain Withdrawing or Withholding Treatment Under an Advance Directive: ADVANCE DIRECTIVE – Under the Texas Natural Death Act, patients have the right to make advance decisions with respect to the use of “heroic” measures should they become terminally ill Typically, such patients will set forth their desires in an instrument known as an “Advance Directive to Physicians”, commonly referred to as a “Living Will” Other patients may have “Durable Power of Attorney for Healthcare” The principal distinction between the two instruments is that the durable power of attorney authorizes another person to make a treatment decision for the patient if he or she is incapable of doing so An advance directive, by contrast, instructs the physician not to administer any life-sustaining measures The typical directive provides, in relevant part, as follows: “If at any time I should have an incurable or irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, and if the application of life-sustaining procedures would serve only to artificially postpone the moment of my death, and if my attending physician determines that my death is imminent or will result in a relatively short time without the application of life-sustaining procedures, I direct that those procedures be withheld or withdrawn, and that I be permitted to die naturally ” “In the absence of my ability to give directions regarding the use of those life-sustaining procedures, it is my intention that this directive be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from that refusal ” If a patient has an advance directive to physicians, it should be followed, subject to the following conditions The attending physician must first certify that the patient is a “qualified patient” who suffers from a “terminal condition” Tex Health & Safety Code Ann Sec 672 010(a)


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QUALIFIED PATIENT – A “qualified patient” is a patient who suffers from a “terminal condition” that has been “diagnosed and certified in writing by the attending physician and one other physician who have personally examined the patient” Id Sec 672 002(8) A “terminal condition” is defined as “an incurable or irreversible condition caused by injury, disease, or illness that would produce death without the application of life sustaining procedures, according to reasonable medical judgment, and in which the application of life sustaining procedures serves only to postpone the moment of the patient’s death” Tex Health & Safety Code Ann Sec 672 002(9) (Vernin 1992) A “life sustaining procedure”, in turn, is defined as “a medical procedure or intervention that uses mechanical or other artificial means to sustain, restore, or supplant a vital function, and only artificially postpones the moment of death is imminent or will result in relatively short time without the application of the procedure The term does not include the administration of medication or the performance of a medical procedure considered to be necessary to provide comfort or alleviate pain” Id Sec 672 002(6) Prior to ordering the withdrawal or withholding of life-sustaining procedures, the attending physician must: Determine that the patient’s death is imminent or result in a relatively short time without application of those procedures; Note that determination in the patient’s medical record; and Determine that the steps proposed to be taken are in accord with the patient’s existing desires Id Sec 672 010(b) if these conditions are met, life-sustaining procedures may be withheld or withdrawn PATIENT WITHOUT ADVANCE DIRECTIVE – In other instances, the decision making process is more complex If the patient is an adult, but does not have a directive, it is possible for him to make a “non-written” (i e , oral) directive Id Sec 672 005 Similarly, if the patient is an adult, does not have a directive, and is incompetent, comatose, or otherwise incapable of communication, he or she may issue (through family members) what is known as a “presumed intent” directive Id Sec 672 005 (Note that a patient is “incompetent” if he or she “lacks the ability, based on reasonable medical judgment, to understand and appreciate the nature and consequences of a treatment decision, including the significant benefits and harms of and reasonable alternatives to a proposed treatment decision”) Id Sec 672 002(5) Regardless of whether the patient is or is not “incompetent, comatose, or otherwise incapable of communication”, the first step is to determine whether the patient is a “qualified patient” who suffers from a “terminal condition” Again, this determination requires the diagnosis and written certification of the attending physician and another physician who has personally examined the patient If the patient is competent and capable of communication, the directive must be issued in the presence of the attending physician and two disinterested witnesses Id Sec 672 005(b) The witnesses may not be: • Related to the patient by blood or marriage; • Entitled to inherit any part of, or would have a claim against the patient’s estate; • The attending physician; • An employee of the attending physician; • An employee of the hospital who is involved in the “direct” care of the patient or an employee • “directly involved” in the “financial affairs” of the hospital; or Another patient in the hospital Id Sec 7620038 PATIENT WITHOUT ADVANCE DIRECTIVE, INCOMPETENT, COMATOSE OR OTHERWISE INCAPABLE OF COMMUNICATION – If this patient is an adult, a treatment decision to withhold life-sustaining procedures may still be made If the patient has a legal guardian, the attending physician and guardian may make the decision Id Sec 672 009(a) If the patient does not have a legal guardian, the attending physician and two of the patient’s relatives, “if applicable”, may make a treatment decision to withhold or withdraw life sustaining procedures Id Sec 672 009(b) The two persons authorized by statute to make the treatment decision with the attending physician are, in the following priority: • The patient’s spouse; • A majority of the patient’s reasonably available adult children; • The patient’s parents; or • The patient’s nearest living relative


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The decision in this instance must be made on the basis of what the patient would desire Id Sec 672 009© This can be done by documenting, in the medical record, statements by the family members as to past expressions by the patient Again, however, the treatment decision must be made in the presence of two disinterested witnesses Id Sec 672 009(d) In the event the members of the patient’s family do not agree to the withholding or withdrawal of life sustaining procedures, the best course of action is to continue treatment, and advise the family members who favor withholding or withdrawing treatment to secure a court order appointing them as the patient’s guardian and authorizing them to make the decision MINOR AND PREGNANCY – Finally, there are three important points that must be kept in mind In cases involving the withholding or withdrawal of treatment from a minor, the decision must be made by the patient’s spouse (if he or she is an emancipated adult), the parent’s, or the patient’s legal guardian Id Sec 672 006 Second, if the patient is pregnant, life-sustaining procedures may not be withheld or withdrawn, even if the patient has executed a written directive Id Sec 672 019 Third, the forgoing procedures are not required if the patient is deemed to be legally dead due to the irreversible cessation of brain function; in this latter instance, however, the patient’s death must be pronounced before artificial means of supporting his or her respiratory or circulatory functions are terminated Id Sec 671 001 © LIFTING SAFELY TO PROTECT YOUR BACK Back injuries are the most common type of injuries among health care workers in hospitals and nursing homes You can prevent them by learning about your back and using your body correctly to lift and move patients and objects SAFE LIFTING TIPS: Never reach above your shoulders – use a step stool or ladder When reaching down, support your upper body with one arm Always stay close to the load without learning forward Push rather than pull whenever possible When bending, kneel down on one knee Bend your knees and hips – not your back When leaning forward, move your whole body, not just your arms TIPS FOR LIFTING AND MOVING PATIENTS Always stand with your feet slightly apart Bend your knees, not your waist Lift with your legs and keep the patient close to your body to reduce strain Lower patients slowly, bending at the knees Work as a team with co-workers for large or heavy patients Use mechanical aids whenever possible REMEMBER – WHENEVER YOU’RE LIFTING OR MOVING A PATIENT – GET HELP WHEN YOU NEED IT! TIPS FOR A HEALTHY BACK • Keep your back pain free by following these general tips: • Learn proper lifting techniques • Plan ahead and take precautions • Never twist, lift or carry only what you can handle safely • When standing for long periods of time, balance your spine by placing one foot on a low stool, bend your knees slightly, and keep your pelvis titled forward • When sitting, use a chair that allows both feet to be flat on the floor • Always maintain good posture – slouching puts strain on your vertebrae • Use lumbar support cushions for your lower back if you sit a lot


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General Hazard Prevention There are other hazards in the workplace that you can help prevent, such as fire and electrical hazards and slips, trips and falls Everyone must take accident prevention and hazard identification responsibilities seriously The following safety guidelines can help FIRE AND ELECTICAL SAFETY • Report defective electrical outlets, so they can be replaced • Know where fire extinguishers are located and how to use them • Smoke only in designated areas • Use electrical appliances that have three-wire grounded plugs and unfrayed wires • Know fire evacuation plans SLIPS, TRIPS AND FALLS • Common workplace accidents, such as slips, trips and falls, can be avoided when you keep your work area neat and organized • Keep everything in its proper place • Be sure of adequate lighting • Wear shoes with antiskid soles • Close file and desk drawers all the way • Hold the railing on the stairs • Keep one hand free for support or to stop a fall • Clean up or report spills and obstructions • Watch out for wet floors • Use a ladder, not makeshift arrangements • Report loose or worn flooring or torn carpet AVOIDING SLIPS, TRIPS AND FALLS You take hundreds of steps at work each day For each step there are countless potential hazards just waiting to trip you up If you understand how these hazards can cause slips, trips and falls, you can prevent needless and painful injury to yourself, your patients, and your coworkers WATCH YOUR STEP Even common hazards like water spills and burned-out light bulbs can lead to serious, painful injuries – and could also limit your ability to respond to emergencies Protect yourself, your coworkers and your patients by doing what you can to create a hazard-free workplace CLEAN UP WET SURFACES Anytime you see (or cause) a spill, clean it up right away If you can’t, mark it with a sign or paper towels and report it to the appropriate person for cleanup AVOID SHORT CUTS Taking a short cut to save time can be risky The more short cuts you take, the greater your chance for taking a tumble • Find a ladder or a step stool when something’s out of easy reach, instead of using an object not meant for climbing • Never carry a load that you can’t see over If necessary, make more than one trip • Use only designated walkways


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Keep your area clutter free and well lit Every piece of equipment left out or file’s drawer left open is a hazard that can trip you up, particularly when it’s dark, clean up clutter, especially in front of stairs, in hallways and on stairs Don’t leave wheelchairs, cleaning supplies, handcarts and other materials lying around Turn on lights before entering a room or supply closet Replace burned out light bulbs Close file drawers before you walk away from them GOOD HOUSEKEEPING can help prevent accidents Remember: Make daily housekeeping a priority • Use your common sense • Watch our for potential safety hazards • Correct problems or report any unsafe conditions immediately! YOUR SAFETY CHECKLIST How well are you controlling the potential hazards around you? Look at the safety precautions the people around you are taking in the workplace How do you compare? Read the list below and check each true statement The more boxes you check, the more you’re contributing to a safe workplace • I take the time to get a ladder instead of climbing on a box or chair • I clean up or report spills I see or cause • I put away supplies and work materials instead of leaving them lying around • I choose to carry two smaller loads instead of one large one • I close file cabinet drawers before walking away • I replace or report burned out bulbs so the next person won’t be caught in the dark Medication Error Tracking System A medication error by definition is a dose of medication that deviates from the physician’s order as written in the patient’s medical record or from current hospital policy and procedure Except for omission, the medication dose must actually reach the patient A wrong dose that is detected and corrected prior to administration is NOT a medication error, but must be reported on a Drug Discrepancy Form A prescribing error is also excluded form this definition Classification of incidents: Level 0 – non-medication error occurred (potential error) Level 1 – an error that did not result is patient harm Level 2 – an error that resulted in the need for increased patient monitoring, but no change in vital signs and no patient signs Level 3 - an error that resulted in the need for increased patient monitoring with a change in vital signs, but no ultimate patient harm, or an error that resulted in the need for increased laboratory monitoring Level 4 - an error that resulted in the need for treatment with another drug or an increased length of stay or that affected patient participation in an investigational drug study Level 5 - an error that result in permanent patient harm Level 6 - an error that resulted in patient death


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REPORTING: 8 Follow Policy of Facility 9 Notify Physician of medication error 10 Incident Report and notify charge nurse FOOD & DRUG INTERACTION A food & drug interaction may occur when certain types of food either potentate or decrease the effect of the medication The health care provider is responsible for identifying when a food & drug interaction may occur, counseling the patient, and preventing future food & drug interactions It is your responsibility to follow policy and procedure of your facility In the hospital usually three different departments are involved in implementing policy and procedures: • PHARMACY • NUTRITION SERVICES • NURSING A Typically Pharmacy has the responsibility to: Provide for all prescriptions filled, as appropriate, to include auxiliary labels, written information, and/or face-to-face counseling for Potential food & drug interactions Flag the identified drugs on the MAR’s with **Potential FDI to alert nursing personnel that the patient is receiving a drug which may have a potential food & drug interaction Serve as a consultant to provide in-depth education on food & drug interaction Publish a newsletter, which includes information on food & drug interactions B Typically Nutrition Services have the responsibility to: Provide counseling to patients on potential food & drug interactions based on their unit specific procedure Identify which patients are on Lasix, Coumadin, Antabuse, MAOI’s Lithium and Humalog, and modify the diet if needed to avoid potential food & drug interactions Serve as consultant for in-depth food & drug interaction education C Typically nursing has the responsibility to: Identify which patients are receiving drugs which have potential food & drug interactions by reviewing the MAR’s and looking for **Potential FDI in the comment section Educate patient on the food & drug interaction and provide them with a copy of the Food and Drug Interactions handout, available in English and Spanish Order consults with pharmacist and/or dietitian as needed Notify nutrition services by diet order of any food allergies Documentation can be found on the Multidisciplinary Patient Education Record and Discharge Instructions form as appropriate The drugs, which are selected to be flagged by the pharmacy on the MAR’s and by nutrition services, are those drugs which are high risk to patients and high volume in usage at the hospital Patients may call the pharmacy and nutrition services at the listed phone numbers on the Food and Drug Interactions handout if they have any further questions once discharged from the hospital Several tools are available to educate staff on food & drug interactions and they include: Medical chart dividers, food & drug books, MicroMedex, and the Food and Drug Interactions handout Keep Yourself Safe and Healthy at Work The everyday operation of a health care facility may create numerous risks that can serious – even tragic – consequences This type of environment makes safety a top priority That’s why your employer has rules and regulations to help keep you safe on the job With the participation, compliance, and commitment of the entire staff, accidents, injuries and illnesses can be significantly reduced Help make your work environment safe Always follow safety guidelines, precautions, policy and procedures of facility and unit you are working on


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FIRE SAFETY TRAINING Most Hospitals are protected with automatic Fire Alarm systems The systems simultaneously give a local alarm within the hospital and notify the fire department upon activation The alarm system gives both an audible and visual signal within the facility Activation of the alarm automatically releases the electromagnetic door holders, thus providing compartmentalization of the fires and closes dampers in the air-conditioning units to control the spread of fire and smoke If during the fire alarm activation, you notice trouble with the system such as a siren not sounding, light not flashing or automatic fire doors not releasing or closing properly, notify Engineering Services PREVENTING THE SPREAD OF INFECTION Careful precautions are the keys to infection control Without proper precautions, germs can easily spread among patients, visitors and staff That’s why health-care facilities take special steps to prevent infection Your cooperation is vital Each patient and visitor plays a role in preventing the spread of infection For instance, staff – and visitors – must wash hands thoroughly and use protective gloves, masks and gowns, as recommended UNDERSTAND HOW INFECTION SPREAD To spread, an infectious disease requires each of the following: A disease-causing organism – Most infectious diseases start with germs (viruses or bacteria) A place for the organism to live – Germs thrive in moist environments The human body offers many good hiding places Germs may also live on objects such as door handles or bedrails, or in substance such as human wastes Vulnerable hosts – Germs don’t always cause disease in every person they contract They require victims who are too weak to fight them off – for example, newborns, older people and the ill or injured Health-care facilities are full of vulnerable hosts A route of transmission – For a disease to spread, germs must have a way to travel to susceptible hosts Different germs travel I different ways, including: • by contact between people (shaking hands, hugging, etc ) • in droplets from coughs or sneezes, which can travel several feet in the air • on tiny dust particles that travel long distances in the air YOU CAN STOP GERMS BY STOPPING THEIR ROUTE OF TRANSMISSION This is the focus of every healthcare facility’s infections control program MSDS – INFORMATION The company sending the chemical supplies material Safety Data Sheet (MSDS) They come in different lengths and formats, but they all contain the same basic information: Key points to look for: • The chemical name • The hazardous ingredient • Descriptive information (color, odor, appearance) • Explosive and fire information • Health hazards • Symptoms of overexposure • Medical conditions aggravated by this chemical • Port of entry into your body (skin, lungs) • Cancer causing / Yes or No • First Aid and emergency procedures • Identify other substances that may react with this chemical • Clean up of leaks and spills to include use of personal protective equipment and how to dispose of the waste • Take a few minutes and look at the manual in your work area Get to know the MSDS’s for the chemicals in your area before there is a problem


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Ethics Committee ready to assist you, your patient and your patient’s family! Making decisions about health care often involves difficult moral and ethnical questions It can be hard to know what is the right thing to do Your personal beliefs, values and goals may differ from those of your patient or other health care providers For example, decisions regarding withdrawal or withholding of life support can be very difficult decisions for your patient/family to make Because your patient’s family and other health care providers share responsibility to make decisions, disagreements or conflicts may develop about what should be done If ethical problems or conflicts cannot be resolved by talking with the patient/family, physician or hospital staff, you can request review or consultation with the Hospital Ethics Committee This special Committee is made up of doctors, nurses, social workers, administrators, chaplains and others who have been trained to deal with these moral and ethical issues One of the Committee’s jobs is to support patients; families and health care providers who are trying to make these difficult decisions Follow procedures on your unit The Committee does not make treatment decisions If is there to provide advice and recommendations to you and your health care providers

UNIVERSAL/BSI PRECATIONS These are a central part of the infection control program Anyone who has contact with a patient – including visitors – should understand how they work The purpose of universal precautions - The Universal/BSI precautions aim to prevent transmission of germs that travel in blood and other body fluids and substances HIV, the virus that causes AIDS, is one such germ The virus that causes Hepatitis B is another Why Universal/BSI precautions are used – It isn’t always obvious that a person is infected with HIV and certain other germs So, Universal/BSI precautions apply to all patients every time contact with blood or other body fluids or substances are possible VISITORS/STAFF MUST OBSERVE UNIVERSAL/BSI - How Universal/BSI work • Hand-washing – Everyone who has contact with patients must wash hands: • after contact with blood or other body fluids or substances (or with equipment the touches these) • after removing gloves, masks and other protective gear Use of Gloves – health-care providers, staff and visitors must wear gloves whenever contact of blood or other body fluids or substances is possible Use of masks, goggles and other protective gear – These help protect the health-care provider’s face and skin form contact They’re used during any procedures where contact with blood or other body fluids or substances may occur Handling wastes – Anyone handling wastes, linens or care items must avoid contact with blood or other body or other body fluids of substances Staff must dispose of needles and other sharp items in special containers Visitors should seek advice from staff on disposal of items that might be contaminated


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UNIVERSAL/BSI APPLY TO EVERY PATIENT ALL THE TIME • • • • • • • • •

The use of Universal/BSI does not necessarily mean a patient has an infectious disease USE THIS TECHNIQUE: Remove jewelry Use warm water Angle hands downward Apply soap and lather well Scrub well for at least 10-15 seconds – its friction that removes germs Get under nails, around cuticles and between fingers Rinse hands angled down Dry hands with a clean paper towel or an air dryer Use a new paper towel to turn off the faucet

WASHING HANDS PROPERLY MAKES A DIFFERENCE The hands are home to a great many germs – and a major means of germ transmission • • • • • • • • • • • •

Wash your hands frequently Visitors should wash hands before and after visits Wash immediately after any contact with potentially infectious material (blood, saliva, etc) Follow standard and transmission – based precautions, as appropriate Use recommended protective wear If asked by the health-care team, visitors should wear gloves, gowns and/or mask Put protective-wear on before entering the room Put the gown on first, then the mask then the gloves Remove in reverse order Avoid touching the outer surfaces of the protective wear Remove gloves by pinching cuff of first glove and peeling back Slide your ungloved fingers under cuff of second glove and peel back Dispose of protective wear as recommended Wash hands

THE STAFF WILL BE HAPPY TO EXPLAIN THE REASONS FOR ANY PROCAUTIONS HELP KEEP INFECTION UNDER CONTROL


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Abuse & Neglect Competency

In this packet you will find the answers to these Questions: • What is patient abuse? • What kinds of patient abuse are there? • What should I do if I suspect a patient is being abused? • What should I do if I feel a patient is abusing me?

Patient Abuse is defined as: “An act against a patient (whether provoked or not provoked) which involves physical, psychological, sexual or verbal abuse” A comprehensive list of patient’s rights is posted on each unit: Right to privacy Right to treatment with dignity Right to receive prompt and appropriate treatment Patients will not be denied their legal rights while hospitalized Right to communicate freely and privately Right to receive unopened mail Right to social interaction Patients will be afforded opportunity to write letters and be assisted in doing so Right to wear own clothes and to keep personal possessions Right to religious worship Right to keep and spend own money All information is kept confidential Right to make decisions involving health care Right to have information to make decisions consistent with wishes Memorandum No 00-7 There are many forms of Patient Abuse such as: Mental abuse and Physical abuse Physical abuse is the type that often comes to mind first Abuse may also be Non-Verbal Intimidation Ridicule Teasing Harassment Scolding Harsh Speech Threatening Indifference Rudeness Deliberately Provoking All are types of verbal abuse/sexual abuse We have all heard nurses make comments like these to the patients in their care Although we tend to overlook it, verbal abuse is more common than we like to admit Verbal Abuse “Just look at the mess you’ve made!” “Can’t you do that yourself?” “You’d better drink this or we’ll put a tube down your throat!”


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Physical Abuse Physical abuse is described as contact, which may do bodily harm Pinching, Striking, Unnecessary Roughness, and Feeding Patient too Fast Neglect is a form of patient abuse This would be failing to attend to the patient’s needs INTENTIONALLY Leaving the patient unattended for long periods - Failing to check the patient in restraints - Not screening the patient to provide privacy Penalties for patient abuse depend on the seriousness of the offense and on the reasonably established evidence Possible penalties include: Written counseling by supervisor, written reprimand which goes in the personnel record, Suspension, and Dismissal What is your responsibility if you observe or suspect abuse of a patient of any probable or claimed occurrence of patient abuse? • First: Secure and protect the patient • Second: Report promptly to your immediate supervisor and give the facts • Third: Fill out an incident report How do you deal with a patient who is Abusive to staff???? The competent patient who is physically abusive may be subject to disciplinary action If the patient is not competent, the Interdisciplinary Treatment Team must meet so that the treatment plan is appropriately modified How might be the best way to deal with a verbally abusive patient? Keep your cool! If the patient has asked a question, answer it calmly and objectively Make sure the patient will be safe Leave the room for a short time Be sure to tell the patient when you plan to return Document the behavior on the medical record Be sure that the patient has a good interdisciplinary treatment plan so that there is uniformity their care This decreases the opportunity for manipulation by the patient Keep in mind that the safety of the patient is a priority at all times!


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Age Specific Competencies

By developing age-specific and cultural competencies, you can help your organization meet JCAHO standards Age-specific and cultural competencies are tools for learning more about how to best meet each patient’s unique needs as you care for him or her There are many ways to learn about each patient’s specific needs Depending on the patient and your job, it may be appropriate to: • Ask the patient questions (and talk with his or her family) • Ask your supervisor for information or training • Look for clues, such as what the patient wears or keeps in his or her room, or how he or she acts • around others Talk with co-workers, community members or others who may know about the • needs of people in a certain age or cultural group Read about the culture or age group (look for • information in your organization’s library or a local library) Each patient is unique Always keep in mind that: Growth and development follow general patterns But every person grows and develops in his or her own unique way Not every member of a cultural group may share all of its values, beliefs or practices A patient may appear similar to you, but still be different from you in certain ways Avoid stereotyping a patient - - consider all the factors that may affect his or her care needs EDUCATION Helps ensure that patients and families get the information they need to have healthy habits and to take part in care It includes assessing learning needs, abilities, preferences and readiness to learn Factors to consider may include: cultural and religious practices, language needs and any needs for access to schooling, for school-age patients How are the education needs of patients and families assessed? IMPROVING ORGANIZATION PERFORMANCE Helps ensure continued improvement in patient health outcomes It involves: • Evaluating how well tasks are performed • Considering patients’ and families’ views about how well care meets their needs and expectations (for example, the helpfulness or education about safe medication use ) How are patients’ and families’ views included in efforts to improve performance? MANAGEMANT OF HUMAN RESOURCES Helps ensure that staff are competent to do their jobs One key area is assessment of a staff member’s age-specific competencies What special skills and knowledge does my job require for the age groups I work with? How is my job competence assessed? What is my organization’s policy about excusing an employee from a duty if his or her values or beliefs conflict with a patient’s? Know the other JAHCO standards, too For each standard, ask yourself and your supervisor How can I do my job better to help meet the age-related cultural and other care needs of our patients? By developing age-specific and cultural competencies, you can help your organization meet its goals for providing quality care to each patient Age-specific competencies involve understanding the development, and the health needs, of the age groups you work with You may work with:


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• Infants and toddlers • Children • Adolescents • Adults Cultural competencies involve understanding and respecting the patient’s cultural values, beliefs and practices It’s important to consider: • Views about health and health care • Family and community relationships • Language and communication styles • Ties to another country or part of the US • Food preferences • Religion • Views about birth and death • Other factors that may affect care needs It can help to have some basic knowledge about the major cultural and religious groups your organization serves, to use as a starting point What primary age groups does my organization serve? What other age groups do we work with in caring for our patients? What cultural groups do we serve? What religious groups do we serve? What languages do our patients speak? Age-specific competencies for infants, toddlers and young children Infants and toddlers (birth to age 3) Healthy growth and development • Physical growth and development are rapid, especially in infancy Building muscle skills is important – from rolling and standing as an infant to running and drinking from a cup as a toddler • Developing trust and a sense of being loved is important in infancy It helps the toddler’s attempts at independence Play is important to help build social and other skills • Infants communicate by crying and making simple sounds Toddlers learn simple words and sentences Ways to provide age-specific care • Educate parents about the need for checkups, screenings and immunizations • Ensure the child’s safety and comfort For example, keep crib rails up, offer age appropriate toys, cuddle an upset child and talk in soothing tones • Explain procedures to parents and the child in simple terms Allow time for questions Let the child touch equipment, or try it on a doll or stuffed animal • Keep the child with parents if possible Involve parents in care (for example, have them choose their child’s food) Have parents demonstrate procedures back to you to show understanding • Discuss parents’ questions and concerns about caring for their child Teach about feeding, hygiene, safety and other ways to promote healthy development Young children (ages 4 to 6) Healthy growth and development • Children grow more slowly during these years They are active, and develop strength and coordination They are able to dress themselves and are toilet-trained • Young children are aware of others’ feelings They may have fears (for example, about being separated from parents or being injured ) They enjoy playing with other children and make friends They begin to develop a sense of privacy • Young children are curious and imaginative They ask lots of questions and enjoy conversations They like stories and make-believe play Ways to provide age-specific care • Continue to stress to parents the need for checkups, screenings and immunizations • Explain procedures and objects in ways the child can understand Avoid words that might be scary


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Show how equipment is used Use toy equipment or other visual aids Give the child chances to help • Reassure the child that the procedure is not a punishment • With a younger child, explain the procedure just before you perform it • Give the child chances to express feelings and ask questions (through talk and play) Encourage a younger patient to bring a security object, such as a blanket • Ask parents about any concerns they may have (for example, with setting limits) Ask the child questions, too (about school or friends, for example) Teach about healthy eating, hygiene and safety, as the child grows more independent How does my job support my organization’s work with infants and toddlers? How do I help meet the unique needs and values of parents and their infant or toddler? How do I involve parents and their child in care? How does my job support my organization’s work with young children? How do I help meet the unique needs and values of parents and their young child? How do I involve parents and their child in care? Age-specific competencies for older children and adolescents Older children (ages 7 to 12) Healthy growth and development • Growth continues at a slower pace until a “spurt” at puberty Muscle skills continue to develop Older children can do a variety of activities, from sports to crafts • Older children can accept rules and responsibilities (such as caring for pets) Completing tasks, mastering new skills and having achievements recognized help build self-esteem Older children enjoy doing things with friends (generally of the same sex) They want more privacy • Older children enjoy riddles, plays on words, etc They can read, write, do math and memorize They have a better understanding of time They enjoy collecting and classifying things Ways to provide age-specific care • Continue to remind parents about the need for immunizations, checkups and screenings • Ask the child about friends, interests, accomplishments and concerns (for example, body changes) Ask for parents’ views, too Allow time for the child and parents to ask questions • Explain procedures and equipment in advance Use correct terms and visual aids Give the child a tour Respect privacy (for example, by keeping the child covered during exams) Give the child chances to help Praise cooperative behavior • Teach the child about healthy and safe behaviors (including not using alcohol, tobacco or other drugs) Encourage parents to talk with their child about these and other important issues (including age-appropriate discussions about sexuality) Adolescents (ages 13 to 20) Healthy growth and development • Girls generally begin puberty about 2 years earlier than boys (it may start in older childhood in girls) A growth spurt may affect coordination for a time Sex features develop (such as breasts in girls and facial hair in boys) • Adolescents are developing an identity They may have emotional swings and face peer pressure They may be self-conscious (about body image, for example) They become interested in close relationships Eating disorders may be a concern • Adolescents can solve problems better They think about the future (for example, their career) They can think more abstractly (for example, about values and about concepts such as justice) They may still not think about long-term consequences of their actions Ways to provide age-specific care • Emphasize the continued need for checkups, screenings, and immunizations • Provide privacy for procedures and teaching Teach using correct terms and visual aids Discuss concerns Encourage involvement in care and decisions Know the age at which and adolescent can legally authorize his or her own treatment • Encourage hospital patients to keep in contact with friends and family


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• Teach about healthy habits (nutrition, exercise, hygiene and safety) Also teach about avoiding pregnancy and health risks, such as sexually transmitted diseases and alcohol, tobacco, and other drug use • Encourage parents to stay involved in their child’s life Give parents and the child information about normal changes of adolescence How does my job support my organization’s work with older children? How can I help meet the unique needs and values of older children and their family? How do I involve older children and their parents in care? How does my job support my organization’s work with adolescents? How can I help meet the unique needs and values of adolescents and their family? How do I involve adolescents and their parents in care? Age-specific competencies for adults ages 21 to 64 Young adults (ages 21 to 39) Healthy growth and development • Young adults reach sexual maturity and their adult height and weight They are more comfortable with their body image • Young adults develop a personal identity and self-reliance They may experience sexual intimacy, choose a mate and raise a family They establish a career • Young adults reflect on changes in their bodies and their lives They can look at problems from different points of view They establish values and use them to make life choices They evaluate new information in terms of their experiences Ways to provide age-specific care • Continue to encourage immunizations, checkups and screenings • Encourage hospital patients to keep in contact with family and friends • Assess the patient for stress related to new adult roles Encourage him or her to talk about feelings and concerns, and about how an illness or injury may affect plans, family and finances • Involve the patient and close family members in decision-making and education Educate about injury prevention and a healthy lifestyle (through exercise, weight control, hygiene, • etc ) Explain the benefits of knowing this information Use appropriate teaching materials Encourage the patient to take part in-group learning situations, such as support groups Middle adults (ages 40 to 64) Healthy growth and development • Adult’s ages 40 to 64 begin to experience physical changes, such as decreased endurance Women experience menopause Illness or injury may interfere with plans Chronic illness may develop • Adults of these ages develop a concern for the next generation They help their children gain independence They may become active in the community (for example, through volunteering) • They develop new roles with aging parents and plan for retirement They begin emotionally preparing for death •These adults may seek further education, possibly to make a career change They are interested in learning They reflect on their lives and accomplishments Ways to provide age-specific care • Continue to encourage checkups, screenings and immunizations • Encourage as much self-care as possible • Allow time to talk about frustrations, accomplishments, dreams and any concerns about illness Talk about stress Provide help with finding resources to meet health-care costs • Educate about healthy lifestyles (stress management, weight management, etc ) Educate about procedures and safe use of medications Use appropriate materials • Involve the patient and close family in decisions about care Start teaching about advance medical directives


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How does my job support my organizations work with young adults? How can I help meet young adults’ unique needs and values? How do I involve young adults and their families in care? How does my job support my organization’s work with middle adults? How can I help meet middle adults’ unique needs and values? How do I involve middle adults and their families in care?

Age-specific competencies for adults ages 65 and older Adults ages 65 to 79 Healthy growth and development • Adult’s ages 65 to 79 experience changes in skin, muscles and sensory abilities They have a higher risk of health problems, such as infection and chronic illness They may sleep more, often by napping during the day Many older adults stay in good health • These adults need to adapt to changes They take up new activities and roles They may experience depression, loneliness and anxiety over changes or about the future • Adults of these ages may have a reduced attention span They may make decisions and remember things (such as names) more slowly They may need more time to learn Ways to provide age-specific care • Stress the need for immunizations, checkups and screenings Encourage healthy habits (nutrition, exercise, hygiene, etc ) and social activity • Educate about safety measures (including fall prevention, safe medication use and using caution with hot water) • Provide a safe, comfortable environment (night light, proper temperature, etc ) Allow time for rest Adapt procedures to physical changes (fragile skin, for example) • Give the patient chances to reminisce, to help promote a positive self-image • Encourage the patient and family to take an active role in care Discuss concerns Talk about family and other support systems Adults ages 80 to older Healthy growth and development • Adult’s ages 80 and older have a higher risk of infections, dehydration, poor nutrition and chronic illness Effects of chronic illness may be more severe Mobility becomes harder • These adults may feel isolated or upset due to loss – of family, friends, sensory abilities or financial independence They may lose self-confidence as their abilities decline • Adults of these ages reflect on their lives and come to an acceptance of death They can still learn, but at slower rates They may have reduced attention spans


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Way to provide age-specific care • Continue to stress the need for screenings, checkups, and immunizations • Encourage physical and social activity Encourage reminiscing • Promote, and assist with, self-care and independence as much as possible Assist with end-of-life planning • Monitor age-related risks, such as skin problems Adapt techniques as needed (for example, using extra caution when moving or touching the patient, to avoid bruising) Allow for frequent periods of rest • Ensure safety measures to prevent falls and burns Educate about home safety and safe medication use • Educate in an appropriate environment with suitable materials Involve the patient and family or other caregiver Teach while the patient is at peak energy Avoid rushing How does my job support my organization’s work with adults ages 65 to 79? How can I help meet the unique needs and values of adults ages 65 to 79? How do I involve adults ages 65 to 79, and their families, in care? How does my job support my organization’s work with adult’s ages 80 and older? How can I help meet the unique needs and values of adult’s ages 80 and older? How do I involve adult’s ages 80 and older, and their families, in care?


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Protective Devices Restraints & Restraint Alternatives Protective Devices Restraints – Restraints Alternatives Purpose: The purpose of this module to acquaint new nursing staff concerning the restraint-proper environment Introduction: Nursing service discourages the use of restraint devices except in instances where patients could harm themselves or others without the devices When the use of a restraint device is deemed necessary as part of the treatment plan, it is important that nursing staff understand how to use them correctly for the safety of patients/residents and to protect themselves professionally and legally Instructions: Read the objectives of the module Read the content of the module Read “Use of restraints and Seclusion” Read each section Complete the posttest within the appropriate section and submit your answers Objectives: 1 Identify the components of a valid order for restraints 2 List alternatives to restraints 3 Identify observation and documentation requirements with the use of restraints 4 State the least restrictive restraint that should be used within a given situation Definition of Restraint: A restraint is any method (physically or chemically) of restricting a person’s freedom of movement, physical activity, or normal access to his/her body and in which the individual cannot remove easily PROTECTIVE DEVICES RESTRAINTS – RESTRAINTS ALTERNATIVES EFFECTS OF RESTRAINT USE Restraints can be useful by allowing needed treatment for combative or confused patients but they can cause serious harm Negative physical effects include: • Pressure sores • Skin abrasion • Incontinence • Decreased muscle strength and muscular atrophy • Constipation • Nerve compression • Pneumonia Psychosocial Adverse Effects Include: Social isolation Panic and fear Agitation and confusion Anger Apathy Withdrawal


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ASSESSING THE PATIENT IS THE FIRST Ask why the restraint is needed for the patient If the patient has a history of falling, the following needs assessed: What time of the day does the patient fall Where do the falls occur Does the patient experience any symptoms prior to falling What was the patient attempting to do prior to the fall Intrinsic risk factors related to falls Impaired vision Lower extremity dysfunction Cognitive impairment Bladder dysfunction Medications Postural hypo tension Extrinsic factors related to falls Elevated bed height Bedside rails compromising bed exit Low seated chairs Low seated toilets without grab rails Poor lighting Slippery floors Bedroom and hallway clutter Improper walking device Faulty footwear Medical assistance devices (IV pole) Psychosocial factors to consider Recent admission (can be very stressful) Memory/recall ability (can not remember that he cannot walk independently) Problem behaviors (wandering, disruptive) PROTECTIVE DEVICES RESTRAINTS – RESTRAINTS ALTERNATIVES CONSIDER ALTERNATIVES Alternatives to restraints foster maximum patient functioning Identifying successful restraint alternatives requires an individualized team approach Consider environmental changes • Adjust bed height to reduce risk of falls • Place often used items within easy reach • Apply non-slip strips to flooring where needed • Improve lighting • Put stop signs or other visual barriers at restricted doorways for wanderers Attend to physiological needs Medicate for pain Avoid constipation Provide for incontinence, check often to see if they need toileting Prevent dehydration Stimulate senses if sensory deprived Decrease noise if agitated/provide for naps Observe for adverse medication effects Use supportive devices for patients with poor balance/posture control


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Use wedge cushions or posey grip to prevent sliding out of chair Provide lateral/anterior torso supports and cushions to prevent leaning while sitting in chair Have patients wear non slip footwear Note: Any supportive device that a patient cannot remove and wants to remove in order to ambulate or have free movement of his/her extremities is considered a restraint Provide for activity Enroll in walking program Give patient small chores to do if appropriate Arrange for group activities Use volunteers, friends or family members to provide companionship Consider the use of alarms Personal alarms Bed/wheelchair alarms - These devices are available through our SPD Re-evaluate the need for a medical device such as an IV or nasogastric tube if the patient keeps pulling at these devices NOTE: Mittens are often used with patients who have a nasogastric tube If the mitten is NOT tied down to an immovable object it is NOT considered a restraint in the medical/surgical or intensive care units However, ANY use of mittens either tied down or not IS considered a restraint in the nursing home care units CARE OF THE AIMLESS WANDERER The aimless wanderer paces without purpose This patient is often found in and out of other patients’ rooms He/She has a short attention span and is easily distracted When managing the aimless wanderer: Observe frequently Keep the hallways free of obstacles Provide adequate lighting Use half-sided bedrails Provide safe footwear Electronic alarms may be helpful Provide regular toileting PROTECTIVE DEVICES RESTRAINTS – RESTRAINTS ALTERNATIVES CARE OF THE PURPOSIVE WANDERER The purposive wanderer is more difficult to manage because this patient becomes easily agitated and may have co-existing behavior problems The purposive wanderer has a specific goal or objective that he/she is attempting to reach When managing the purposive wanderer: Early identification of this type of patient is important Provide a structured/consistent approach Focus on the emotion or need expressed, not the action Walk with the patient Do NOT attempt to orient to reality Do NOT argue AVOID restraining


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CARE OF THE AGITATED/DISRUPTIVE PATIENT When managing this patient: Prevent the behavior if at all possible Include family input in care plan Provide liberal visiting with loved ones Ensure continuity of staff Convey calmness/friendliness Do NOT rush patient EDUCATE PATIENTS AND FAMILIES Patients and families need to receive education concerning alternatives to restraint use, the correct application of restraints and attention to the special needs or restrained individuals Families may often act as an alternative to restraint use while family members are present with the patient THE USE OF SIDE RAILS Side rails on beds are used extensively in hospitals and nursing homes A misconception is that side rails are an effective and/or benign safety device Depending upon the patient’s status, all types of side rails pose an increased risk to safety This risk is increased regardless of the patient’s condition when side rails are used in combination with any physical restraint attached to the body such as vest/chest, waist, and leg/arm The most common form of injury to persons enclosed by side rails occurs when the patient climbs over the rails and falls to the floor A second type of injury relates to injuries caused when patients are trapped between the side rails and the mattress or bed frame in a way that can cause death These injuries are more common when there is miss-sizing of bed and mattress and/or when patients are confused, restless, agitated, ambulatory and/or partially independent in transferring Finally, side rails can cause adverse effects related to immobility and deleterious psychological effects NOTE: Any use of side rails for patients in a nursing home is considered a restraint However the use of side rails for patients in the medical/surgical or intensive care units are NOT considered a restraint REMEMBER! RESTRAINTS ARE A LAST RESORT ONLY THE LEAST RESTRICTIVE RESTRAINT IS USED


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HIPAA Lesson 1 What Information Is Protected by HIPAA Privacy Regulations? Introduction This lesson will help you understand what information the HIPAA privacy regulations protect Agencies/facilities have established both organization and departmental policies and procedure on handling protected health information (PHI) to help you comply with the law To help you recognize PHI in all its forms, we’ll tell you what the law requires and give you seven rules for identifying PHI There’s a quiz at the end of the lesson to help you test your understanding of PHI Definition of PHI Let’s review the definition of PHI Information is Protected Health Information (PHI) if it: • is created or received by a health care organization subject to HIPAA • identifies an individual or there is a reasonable basis to believe it could be used to identify an individual; and • is related to the individuals past, present, or future physical or mental health or condition Forms of PHI - Information can be protected health information (PHI) regardless of whether it is: • spoken (for example, a conversation between a doctor and a nurse), • on paper, or • electronic 7 Rules - There are seven rules you can use to identify what information constitutes PHI Each rule will be discussed in detail Rule 1 – PHI Can Be Written or Oral Written PHI: A patient’s medical record is an obvious example of PHI However, there are many other written materials around the agency/facility that you may not think of as being particularly sensitive bout could, in fact, be considered PHI Here are a few examples of written items that could be considered PHI under the right circumstances: • A sign-in sheet in a reception area if it includes the patient’s name and the reason for her visit; • A code that documents a specific health procedure or test received by an individual; and • A patient identification bracelet or badge or an insurance card Oral PHI: Oral communications, too, can be considered PHI, including: • A conversation with a colleague in the hallway about a patient’s health • An appointment reminder message left on an answering machine; • A telephone call to verify health insurance coverage; • A patient’s medical record dictated onto a tape; and Calling out a patient’s name in a waiting room Rule 2 – PHI Can Be Recorded on Paper, Computer or Other Media PHI can be information that is written or: • typed on paper, • recorded on or sent by a computer • it can also be information in any other media, such as X-ray films


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PHI can include, not just paper documents stored in a patient’s medical file, but also: • Physician dictation on tape that hasn’t yet been transcribed; • Patient status boards; • Eligibility printouts such as information sheets printed by facility outlining if an individual’s health plan covers a requested health care service; • Patient or member financial records; • Face sheets or cover sheets on health records, such as copies of patient demographic information on files; • X-ray films, pathology slides or monitor strips; and • Test results Computerized PHI can include health information: • appearing on computer monitors and screens; • transferred by magnetic or optical devices from one location to another; • stored or communicated on the Internet; • stored on electronic memory chips, magnetic tapes, discs, or CDs Rule 3 – Information that Reveals the State of a Person’s Health Can Be PHI As you have learned, health information is considered PHI: • if a person is identified and the information is about the past, present, or future physical or mental health or condition of that person • Health or condition can include a variety of situations beyond what you might typically expect Example: “condition” isn’t limited to illnesses; being healthy is also a condition for the purposes of the HIPAA privacy regulations Information that Reveals the State of a Person’s Health Can Be PHI cont’d The following examples include information related to an individual’s health or condition and would be considered PHI under the HIPAA privacy regulations: • An announcement sent to a local newspaper by a hospital naming babies born that day – since birth information if information on a health condition; • A postcard from a fertility clinic reminding a patient of her next treatment since the reminder discloses that the patient has been and will be receiving treatment; • A list of patients who received immunizations as part of preventive care; • Information about the sale or dispensing of drugs, or the sale of medical equipment and devices, like crutches or to a particular individual Even a seemingly insignificant piece of information may provide a lot of information about an individual's condition, or health status Example: The simple fact that Mrs Jones has an appointment with Dr Ross does not seem like a big deal But if Dr Ross happens to be an AIDS specialist, this piece of information suggests that Mrs Jones may have, or think she has, AIDS As a result, it could be considered PHI Information regarding payment for health care services is also considered PHI Billing, coding, claims, and financial information created or received by Presbyterian is PHI That means PHI is used or disclosed when: - A billing clerk from Doctor X's office calls a clerk from Doctor Y's office to get coding information for a patient they've both treated; - A claim for payment from Medicare, Medicaid, or a children's health insurance program Rule 4 – Information Must Be ‘Individually Identifiable’ to Be PHI Not all health information is considered PHI According to the law, the information must:


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• relate to health; and • also be “individually identifiable”

Generally, this means that someone seeing or hearing the health information can identify the person and the information is about Certain information like Social Security numbers and patient account numbers are unique to an individual and can be used alone to identify a person Health information that can be linked with their unique identifying numbers or codes that relate to either the individual their relatives, employers, or household members is considered PHI Example 1: A medical record numbers is assigned to a specific patient A blood test result lists the patient’s medical record number, so the report can be filed in the appropriate patient chart Even though it may not contain a patient name, the report is considered PHI since it contains an identifying number Example 2: After a patient is discharged from a hospital, an empty prescription bottle is found in her room The bottle label shows patient’s name, the doctor’s name, the drug’s name, and dosage instructions The label is considered PHI because it discloses both the patient’s name and information about her health or condition; namely, the she takes a certain drug Rule 5 – Health Information Can Be PHI If There Is a Reasonable Basis to Believe It Could Be Used To Determine a Person's Identity Sometimes, one item of information alone won't identify a person, but a combination of items will: Example: A ZIP code, by itself, does not reveal a patient's identity But a combination of items, like a ZIP code and a street address, may give you a reasonable basis for linking health information to a particular person If it does, the health information is considered PHI A reasonable basis for determining a person's identity means that, without taking any extraordinary measures, someone could link health information to a specific person In order for PHI to be considered de-identified the following identifiers of the individual, his or her relatives, employers, or household members must be removed: • Names; • Social Security numbers; • Driver's license numbers or vehicle license plates; • Telephone or fax numbers; • Addresses or part(s) of an address that reveal a geographic subdivision smaller than a state-for example, a street address, city, county, precinct, or ZIP code; • E-mail address, internet Protocol address (IP) or URL; • Birth dates, hospital admission or discharge dates, date of death or any other dates that a"directly related to an individual"; • Medical record numbers; • Account numbers; • Health plan beneficiary numbers; • Device identifiers and serial numbers; • License or certificate numbers; • Biometrics identifiers, including finger or voiceprints; • Full face photographs or comparable images; • Any other unique identifying number, characteristic, or code that could be used alone or in combination with other information to identify an individual; and • There is not actual knowledge that the information could be used alone or in combination with other information to identify the person who is the subject of the information


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Example: A hospital billing clerk overhears two nurses discussing a patient discharged that day after a serious asthma attack The nurses remark that the patient had trouble arranging transportation home, mention her neighborhood, and refer to the patient as "she " None of the items of information by itself, the neighborhood, the patient's sex, the date of discharge, or the health information (the asthma attack) would be enough alone to identify the patient But together, they may provide a reasonable basis to identify the individual The billing clerk may be able to identify the patient by using a Presbyterian computer system to search by particular fields, such as ZIP code and discharge date Rule 6 – Health Information Created or Received by Presbyterian Can Be PHI Example: Individually identifiable health information created or received by health care providers or insurers covered by the HIP AA law (such as Presbyterian Healthcare Services, Albuquerque Ambulance or Presbyterian Health Plan) is PHI Health care organizations covered by the law include: • Hospitals; • Doctor's offices; • Health plans; • Dental offices; • Pharmacies; • Laboratories; • Chiropractors; • Home health agencies; • Hospices; • Ambulance services; and • Nursing homes Example: A physician gets copies of individually identifiable health information from a lab That information is PHI that must be protected according to the same standards as any PHI the physician collects directly from the patient while under his care Rule 7 – 'De-Identified' Health Information is No Longer PHI Two Methods of De-Identifying PHI: Health information that does not identify an individual or cannot reasonably be used to identify an individual is considered' de-identified' Once health information has been de-identified, it's no longer PHI and is not subject to HIP AA privacy law There are only two methods to de-identify PHI: Method 1 Get an expert's determination that the risk is very small that the information could be used to identify an individual Explanation A person who has expertise in “generally accepted statistical and scientific principles and methods” can determine that there’s only a very small risk that the information could be used alone or in combination with other reasonable available information to


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identify a person The expert must document the methods and reasons for making this determination The only person with the appropriate knowledge and expertise authorized to make this determination for our organization is the actuary employed by agency/facility

Method 2 Strip all the identifiers out of the information Explanation The second way to de-identify health information is to strip all 16 of the identifiers listed in the discussion III Rule #5, above In addition, if Presbyterian knows of any other item of information that could be used alone or in combination with other information to identify the individual, even though it's not one of the listed 16 identifiers, it must remove that item, too Whichever method it uses to de-identify health information, the health care organization may want to assign a code to make the de- identified information re-identifiable later This is okay if: • The code isn’t derived from or related to information about the individual (i e : a patient’s Social Security number in reverse order) and isn’t otherwise capable of being translated so as to identify the individual; and • The health care organization keeps the code secret and doesn’t use or disclose it for any other purpose


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The 7 Rules for Identifying PHI at a Glance Use these 7 Rules to help identify PHI: Rule 1 PHI Can Be Written or Oral Rule 2 PHI Can Be Recorded on Paper, Computer, or Other Media Rule 3 Information that Reveals the State of a Person's Health Can Be PHI Rule 4 Health Information Must Be 'Individually Identifiable' to Be PHI Rule 5 Health Information Can Be 'Individually Identifiable' and Therefore, PHI, if It Gives a Reasonable Basis for Determining a Person's Identity Rule 6 Health Information Can Be PHI Whether Your Organization Creates It or Receives It Rule 7 Health Information that Is PHI Can Be Turned Into Non-PHI if it's 'De-Identified'

The HIPAA in a Nutshell Privacy Regulations Introduction New federal privacy regulations require health care organizations to protect the privacy and confidentiality of patients or members' health information or face severe penalties: • Individuals, who work for, or volunteer at, healthcare organizations and who have or may later gain access to patients or members' health information will play a critical role in ensuring agency/facility compliance with the privacy regulations • Every employee and volunteer needs to be familiar with what the regulations say because they may also face lines and penalties individually if they violate the law This overview of the HIPAA Privacy Regulations will be followed by a series of lessons that explain in more detail specific aspects of the HIPAA regulations and policies that may affect your job Objectives At the end of this lesson, learners should be able to: 1 Identify what the acronym HIPAA stands for, 2 Describe the type of information covered by the HIPAA privacy regulations 3 List some examples of “protected health information” (PHI) 4 Describe who must comply with HIP AA privacy regulations, 5 State the compliance effective date, 6 Describe the penalties for non-compliance for individuals, 7 Locate and discuss the eight key points of the HIP AA privacy regulations, 8 Describe when a state law would supersede HIPAA Privacy regulations, 9 Follow the tips for keeping computerized information private HIPAA Includes More than Privacy Regulations In 1996 Congress passed the Health Insurance Portability and Accountability Act, a federal law referred to as "HIPAA" Although this training focuses on the privacy regulations, you should be aware that HIPAA covers a number of different health insurance issues in addition to privacy: 2 HIPAA establishes national standards that all health care organizations and insurers must use when


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they exchange health information electronically 3 HIPAA also includes two sets of regulations to safeguard the privacy and confidentiality of patients and members’ health information • One set is the health information security regulations, which deal with how you protect electronic health information from unauthorized access; and • The other set of regulations is the privacy regulations

This training will cover the privacy regulations HIPAA and Other Privacy Laws Other long-standing privacy laws exist, at both the state and national level Federal health insurance programs like Medicare and Medicaid include rules and standards to protect patient and member privacy, as do accreditation agencies like JCAHO and NCQA HIPAA will impact the health care industry more than any previous federal or state privacy laws for several reasons: • HIPAA is the first national law to include privacy protections for all kinds of patients; • HIPAA privacy regulations affect virtually any person or organization that provides health care or health insurance (or handles medical information on behalf of a person or organization that provides those services, and • HIP AA privacy protections for patients and members are more sweeping and detailed than anything in previous laws What Information Do the Privacy Regulations Cover? The privacy regulations cover what's called "protected health information" (PHI) Information is Protected Health Information if it: • is created or received by a health care organization subject to HIPAA; • identifies the individual or there is a reasonable basis to believe it could be used to identify the individual; and is related to the individual's past, present, or future physical or mental health or condition Information can be protected health information (PHI) regardless of the form it is in: • spoken (for example, a conversation between a doctor and a nurse), • on paper, or • electronic Who Must Comply? Two kinds of organizations are affected by the HIPAA privacy regulations: 1 Covered entities – HIPAA privacy regulations apply directly to Covered Entities There are three kinds of covered entities: • Health plans - an HMO or a group health plan that provides health benefits to the company's employees; • Health care clearinghouses - a billing company or repricing company; and • Health care providers such as, physicians, hospitals, and home health agencies Health care providers are covered if they electronically transmit certain health insurance transactions, such as billing, eligibility, or referral transactions Health care providers are also covered, even if they keep only paper records, if they hire a third party to transmit those electronic transactions on their behalf Business associate – An organization (or individual) that's not a covered entity may still be indirectly affected by the privacy regulations if it is a "business associate" of a covered entity The regulations require covered entities to have contracts with business associates that protect PHI Definition: A business associate is an individual or organization that "performs or assists in the performance of' an activity that involves the use or disclosure of protected health information on a covered entity's behalf For example: • billing companies, • claims processing companies,


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• attorneys, • accountants, and • practice management companies

Compliance Effective Date: The HIPAA privacy regulations become effective on April 14, 2003 Penalties for Noncompliance There are stiff penalties for violating the privacy regulations of HIP AA, including possible fines and jail time It is not just the organization that's subject to penalties Members of health care workforce who commit violations may also have to pay fines or go to jail Here are some of the potential consequences of committing a privacy violation: Types of Penalties Consequences of Committing Privacy Violations… Civil Penalties Civil penalties include fines of up to $100 per violation per person, with a maximum total fine of$25,000 for all violations of the same requirement or prohibition in a calendar year Criminal penalties Criminal penalties can include fines and jail time as follows: a Knowingly releasing PHI in violation of HIPAA can result in a fine of up to $50,000, up to a year in prison, or both; b Gaining access to PHI under false pretenses (for example, misrepresenting yourself as a physician so you can see a patient's medical file) can result in a fine of up to $100,000, a maximum fiveyear prison sentence, or both; and c Releasing PHI with harmful intent or selling PHI (for example, selling PHI about a famous patient to the media) can result in a maximum fine of $250,000, a prison sentence of up to 10 years, or both Enforcement: The US Department of Health and Human Services' Office of Civil Rights (OCR) can investigate health care organizations and impose civil penalties Types of Penalties Consequences of Committing Privacy Violations…Continued Other Consequences violating the privacy regulations can also hurt agency’s/facility’s reputation and ham to its competitive position On a more personal level, violating the law or agency’s/facility’s policies may subject you to disciplinary action up to and including the loss of your job Most of all: It hurts the person whose privacy was violated Key Points of the HIPAA Privacy Regulations & Regulation Requirements The HIPAA privacy regulations require organizations to protect the confidentiality of patients and members' health information Here are eight key points to remember regarding the regulations:


Rx Med Staff, LLC

Key Point #

Privacy Regulation

Description and Examples

1

A patient or member authorization isn’t required for uses of disclosures of PHI for treatment, payment, or health care operations

The regulations generally allow the use or disclosure of a patient's or member's PHI without the patient or member's authorization, or permission, when the use or disclosure is for: • Treatment, • Payment for healthcare services, or • Health care operations purposes Exception: Health care organizations may be required to get a patient or member's authorization to use psychotherapy notes for these purposes

2

A patient or member authorization isn’t required for certain other uses or disclosures

The use or disclosure of a patient or member's PHI without a patient or member's authorization is allowed in situations involving: • Public health activities; • Reporting abuse, neglect, or domestic violence; Health oversight activities; • Court cases and administrative hearings; • Law enforcement activities; • Helping coroners determine the identity of a dead person and cause of death; • Eye or tissue donations; • Certain kinds of medical research; • Certain fundraising activities; • Certain, very limited marketing activities such as face-toface conversations; • Efforts to avoid serious threats to health or safety; and Certain government functions such as intelligence, national security, and workers' compensation


Rx Med Staff, LLC

Key Point #

Privacy Regulation

Description and Examples

3

A patient or members must authorize other uses and disclosures

The HIPAA privacy regulations specify certain uses and disclosures that do require a patient or member authorization before the use or disclosure The regulations also list the specific elements that must be in a valid authorization

4

Covered entities must use and disclose the minimum necessary PHI

The privacy regulations generally require organizations to make reasonable efforts to limit their use and disclosure of, and requests for, PHI to the “minimum necessary” to accomplish the intended purpose of the use or disclosure

5

Privacy Regulation Patients and members have new privacy rights

The regulations give individuals six new privacy rights, including the right to: • Receive a notice describing an organization’s privacy practices; • Request restrictions on how an organization uses and to whom it discloses their PHI; • Request that an organization communicate their PHI to them by alternative means (for example, by telephone instead of U S mail) and/or to alternative locations (for example, to their work rather than home address, or in a private area at the hospital instead of a busy waiting room); • Inspect and get a copy of the PHI an organization maintains in records used to • make decisions about them; • Request that an organization make amendments (i e , changes or corrections) to their PHI; and • Get an accounting, or report, of certain disclosures of their PHI in the past six years

6

Health plans must restrict employers’ access to employees’ PHI

Before an employer can receive PHI from a health plan, it must certify in writing to the health plan that it will only use that PHI for certain purposes allowed by law Example: An employer may not use PHI in connection with any employment-related actions or decisions

7

Health plans must restrict employers’ access to employees’ PHI

Before an employer can receive PHI from a health plan, it must certify in writing to the health plan that it will only use that PHI for certain purposes allowed by law Example: An employer may not use PHI in connection with any employment-related actions or decisions


Rx Med Staff, LLC

8

Covered entities must make administrative changes to protect privacy of PHI

Examples of administrative requirements required by HIPAA include: • Appoint a privacy officer; • Train workforce about privacy policies; • Maintain and retain documentation regarding compliance efforts • Establish a procedure for handling privacy complaints; and • Establish a policy to punish privacy violations

HIPAA and State Law: How Does HIPAA Affect State Law? The general rule is that a federal law, like the HIPAA Privacy regulations supersedes or "preempts" state law This means that federal law is usually followed, rather than state law However, if a state law is more protective of privacy than HIPAA, the state law applies If it is possible to comply with both federal and state law, then both laws must be followed Every member of the Workforce plays a critical role in keeping our business and patient information secure when using the computer Please follow these tips for keeping computerized information private: • Never share your password with anyone • Do not-write down your password and leave it in your work area • Do not open unexpected email attachments • Never open attachments from an unknown or suspicious source • Never download freeware or shareware from the internet without express permission from the • Information System (IS) department

HIPPA Practice Questions - Now let's see if you can apply what you have learned in this lesson


Rx Med Staff, LLC

Instructions - Analyze the questions and select the answer you think is right Good luck!

1 a b c d

HIPAA is the acronym for: Hugely Important People from the Automobile Association Health Insurance Portability and Accountability Act Healthy Individuals Prepare Actively Act Health Information Privacy Auditing Act

2 The HIPAA privacy regulations cover what is called "protected health information" (PHI) PHI can be in many forms Which of the following forms is considered PHI? a Oral information For example, two medical staff members are talking about Mrs Garcia's prognosis in an elevator b Written information For example, a consent form for a medical service is filed in a patient chart c Electronic information A claim image is on a computer monitor d All of the examples above are forms of PHI 3 a b c

The compliance effective date for the HIPAA privacy regulations is: December 31, 2002 January 1, 2004 April 14, 2003 As soon as possible

4 a b c d

Penalties for violating the HIPAA privacy regulations can impact: Only the facility Only doctors Facility and any member of facility’s workforce (you) Only health plan members

5 “Workforce” is defined as: a Only employees of agency/facility b Facility’s inpatients and outpatients c Facility employees, plus volunteers, trainees, and other persons whose conduct in the performance of work, is under the direct control of agency/facility, whether or not they are paid d Agency/facility health plan members


Rx Med Staff, LLC

Annual Update Mandatory Competency Post Test Section 1: HIPAA 1 HIPAA is an acronym for Health Insurance Portability and Accountability Act enacted in 1996 by the Federal government a) True b) False 2 HIPAA’s intent is to reduce fraud and abuse, improve quality and efficiency of healthcare, and protects the privacy and security of patient health information and to reduce administrative costs a) True b) False 3 Validating fax numbers and available recipients is NOT necessary under HIPAA a) True b) False 4 Examples of protected health information include name, address, social security number and date of birth a) True b) False 5 Protecting health information requires cautious use of medical records, sign-in sheets, taking of medical histories a) True b) False Section 2: OSHA / Infection Control/ Back Safety/Life Safety / Emergency Preparedness 6 Material Safety Data Sheets (MSDS) contain the following information on chemicals a) What the chemical is called and what is in it b) What happens if you are affected by the chemical and what first aid steps to take c) How to protect yourself and how to work safely with the chemical d) All of the above 7 OSHA requires that employers inform employees of the hazardous chemicals that are in the work place to which they may be exposed a) True b) False 8 Chemicals enter the body through the following “routes of entry” a) Lungs and skin b) Swallowing and injection c) A and B d) None of the above 9 Never use any container without a label describing its contents a) True b) False


Rx Med Staff, LLC

10 In the event of a blood or body fluid exposure a) Complete an Occurrence Report b) Notify your supervisor immediately for instruction c) Follow up with your employee health representative d) All of the above 11 Standard Precautions means that all body fluids are treated as potentially infectious a) True b) False 12 To prevent the spread of blood borne pathogens, you should: a) Wash your hands every time you remove your gloves b) Change sharps containers when they are 2/3’s full c) Dispose of all material contaminated with body fluids in a red bag d) All of the above 13 You must notify your supervisor if you are exposed to any infectious disease, even if it occurred outside of the hospital a) True b) False 14 To prevent the spread of Tuberculosis: a) Wear a HEPA/N95 Respirator when caring for patients in special respiratory isolation b) Complete your annual health screening c) Notify your supervisor immediately in the event of an exposure d) All of the above 15 OSHA mandates that the employee notify Employee Health annually, to be re-fit tested if which of the following has occurred: a) Employee experiences greater than 20 weight change b) Employee now has facial hair c) Significant dental work d) Significant facial plastic surgery e) Change of address f) All of the Above g) A, B, C and D 16 Twisting your body when lifting a patient may result in a back injury a) True b) False 17 Always ask for assistance when lifting or transferring a patient if there is any question on the patient’s ability to assist or if the patient is too heavy a) True b) False 18 Electrical conductors include a) People b) Water or Damp Floors c) Metal d) All of the above


Rx Med Staff, LLC

19 When working around electricity: a) Use a 3 prong plug as it prevents electricity from leaking through the wire b) Inspect electrical equipment for damage before using c) Take the equipment out of service if it is not working properly d) All of the above 20 Emergency care of an unresponsive patient is done in this order: a) Airway, breathing, circulation b) Breathing, circulation, airway c) Breathing, airway, circulation d) Airway, circulation, breathing 21 You establish that a patient is unresponsive after calling HELP, which of these actions should you take? a) Sweep the patient’s mouth b) Administer three quick breaths to the patient c) Open the patient’s airway and check for breathing d) Check the patient’s pulse and initiate cardiopulmonary resuscitation Section 3: Risk Management / Patient Safety 22 A new patient safety initiative for 2005/2006 is: a) Reducing the risk of surgical fires b) Completing your charting on time c) Reducing the risk of influenza and pneumococcal disease in older adults d) All of the above e) A and C 23 Healthcare workers are required to report suspected abuse a) True b) False 24 How many patient identifiers should be used when taking samples, giving medication or blood products? a) 0 b) 2 or more c) 1 25 One way to improve use of high alert medications is to remove these medications from patient care units a) True b) False 26 Medication related abbreviations have contributed to medical errors a) True b) False 27 Ways in eliminating wrong-site, wrong patient, wrong-procedure surgery include: a) Verification checklist process b) Surgical site marking c) Timeout d) A and C e) B and C f) A, B and C


Rx Med Staff, LLC

28 Research indicates that factors contributing to wrong site surgery include: a) Inadequate patient assessment b) Emergencies c) Use of abbreviations related to the surgical procedures, site or laterality d) All of the above 29 Hand washing with alcohol-based hand rubs is the best way to kill bacteria a) Tue b) False 30 Refer to the Facility Policy prior to initiating a Restraint a) True b) False 31 The least restrictive measure for restraining a patient must be used a) True b) False 32 The licensed independent practitioner (LIP) order for restraints must specify: type of restraint, justification, date, time ordered and duration a) True b) False 33 Complications of restraints include: Poor circulation, pressure sores, increased agitation, inability to sleep a) True b) False 34 A fall risk assessment includes client and environmental factors that contribute to falls a) True b) False 35 The 7 rights of medication administration include, right dose, right medication, right patient, right route, right time, right education and right documentation scanned at point of administration a) True b) False Section 4: Population Competencies / Pain Management 36 Care given to all patients in the hospital is based on what is appropriate to their age and developmental level a) True b) False 37 The experience of pain is influenced by: a) Sensory experiences b) Cognitive abilities c) Behavioral processes d) All of the above 38 Pharmacological intervention for pain management can include all of the following except: a) Opioid analgesics b) Antibiotics c) Non-opioid analgesics d) Steroids


Rx Med Staff, LLC

39 Non-Pharmacological interventions for pain management are appropriate for: a) Carefully screened patient populations b) Pediatric patient populations c) Geriatric patient populations d) All patient populations 40 Pain management in geriatric patients: a) Is often complicated by treatments for coexisting diseases b) Is impacted by diminished renal and liver function c) Can be complicated by cognitive deficits d) All of the above 41 Assess patients upon admission for actual or impending skin breakdown and note signs of impending breakdown, which include areas of discoloration, fluctuance (fluid filled feeling) and induration a) True b) False 42 Patients who have decreased mobility of any part of their body may be at risk for pressure sores in those locations a) True b) False Section 5: Risk Management / Chain of Command 43 Occurrence report cannot be filled out by an Rx Med Staff, LLC , Inc employee a) True b) False 44 Critical thinking: a) Is purposeful thinking that is outcome oriented b) Is based on nursing principles c) Is a one time thought process d) A and B 45 Chain of command is: a) A responsibility of the charge R N b) Continuing process of clarification with others c) Reporting of unexpected outcomes d) Physician having ultimate decision making authority e) All of the above f) B and C 46 An Occurrence Report must be: a) Completed by the employee immediately b) Given to the employee’s supervisor before the shift ends c) Factual, report only what happened or saw d) All of the above


Rx Med Staff, LLC

Section 6: Palliative Care/ End of Life Decisions and Cultural Competence 47 Individuals have the right to make medical decisions and to communicate those decisions through an advance directive a) True b) False 48 End of life goals include: a) Keeping the patient comfortable b) Addressing physical, emotional, spiritual, social and financial needs c) Understanding the patient’s need to retain his or her dignity d) Preserving the quality of life e) Providing support and grief counseling f) A, C and E g) All of the above 49 The reason why cultural competence is important in healthcare is because: a) There are healthcare disparities across cultures b) Population demographics are changing c) None of the above d) A and B 50 Hospitals must contract with an Organ Procurement Organization to address every potential donor of their option to donate or not to donate organs? a) True b) False Section 7: Age Specific Competencies 51 Involving family in care can be helpful with patients of all ages? a) True b) False 52 It’s best not to talk about procedures or equipment with a toddler? a) True b) False 53 Older children are not yet concerned about body changes? a) True b) False 54 Young adults evaluate information in terms of their experiences? a) True b) False 55 Young children will not be afraid of being apart from their parents? a) True b) False 56 It’s important to provide adolescents with privacy during teaching and procedures? a) True b) False


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57 Middle adults are in a stable period of little change? a) True b) False 58 Adults ages 65 up may need to receive information more than once and in segments? a) True b) False 59 A young child may view an illness or procedure as punishment? a) True b) False 60 Always discourage activity in adults ages 80 and older, to prevent injury? a) True b) False


Rx Med Staff, LLC

Name:_________________

Date:___________ Annual Mandatory Exam Answer Sheet

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Rx Med Staff, LLC

Name:______________

Age Specific Checklist

Date:__________


Rx Med Staff, LLC

Psychiatric RN Skills Checklist ________________________________ First Name

______________________________________ Last Name

________________________________ Social Security number

______________________________________ Date

________________________________ Email Please indicate your level of experience (0, 1, 2, or 3) 0 = Theory, no practice 1 = Limited 2 = Confident A. MEDICATIONS 1. IV addictives, IVPB, IV push Dilantin Librium Valium 2. Administration of anti-psychotic drugs 3. Management of adverse effects and adverse reaction of antipsychotic drugs 4. Administration of anti-cholinergic drugs 5. Assessment for possible misuse or abuse of anti-cholinergic drugs 6. Administration of anti-depressant drugs 7. Management of side effects and adverse reactions from antdepressants 8. Administration of MAO inhibitors 9. Knowledge of adverse response to MAO inhibitors, dietary restrictions and management of hypertensive crisis 10. Administration of lithium 11. Knowledge of lithium side effects 12. Stabilizing lithium levels 13. Management of patients who are noncompliant with medications and instituting appropriate interventions B. ACUTE CARE INTERVENTIONS 1. Knowledge of progressive containment Medications Seclusions Restraints 2. Knowledge of legal responsibility regarding use of restraint and seclusion 2. Use of interventions with acute suicidal

Psych RN Skills Checklist Page 1 of 3

3 = Very Confident

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Rx Med Staff, LLC

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C. MANAGEMENT OF SUICIDAL PATIENT 1. Crisis intervention on phone 2. Suicidal precautions 3. Knowledge of patients that are high risk

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D. CHILD PSYCHIATRIC 1. Knowledge of child psychiatric disorders and treatments 2. Knowledge of effective child rearing practice 3. Use of PRN medication for behavioral management 4. Family interventions 5. Effects of locked door seclusion on child psychiatric patients 6. Curative factors of the milieu of child psychiatric patient

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F. GERONTOLOGIC PSYCHIATRIC 1. Differentiating depression from dementia 2. Factors contribute to Sun down Syndrome 3. Factors that contribute to withdrawal of elderly 4. Interventions with agitating elderly 5. Interventions with confused elderly 6. Preventive measures for disoriented elderly

0 0 0 0 0 0

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G. LEGAL ASPECTS 1. Knowledge of patient’s right 2. Confidentiality 3. Voluntary and involuntary commitment 4. Discharge AMA

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H. GENERAL PSYCHIATRIC NURSING 1. Use of milieu to enhance patient care 2. Use of milieu to decrease confusion and tension

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3. 4. 5. 6. 7. 8. 9.

Use of interventions with Alzheimer’s Use of interventions with delusional patient Use of interventions with hallucinating patient Use of interventions with organic brain syndrome Use of interventions with physically aggressive Use of interventions with self-abusive Use of interventions with severe to panic level of anxiety

E. ADOLESCENT PSYCHIATRIC 1. Knowledge of technique used to promote an alliance with adolescent 2. Knowledge of effectiveness of limit setting interventions 3. Knowledge of indications, actions and possible side effects of psychotropic drugs on adolescent 4. Knowledge of intake screening

Psych RN Skills Checklist Page 2 of 3


Rx Med Staff, LLC

3. Initiate treatment plans 4. Complete nursing assessment 5. Seizure precautions 6. Knowledge of somatic therapies 7. Knowledge of major categories of abused substances 8. Knowledge of experimental behavioral responses, behavior related to withdrawal syndrome 9. Isolation procedures

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I. Age specific practice criteria

Please check the box corresponding to each age group for which you have expertise in providing age-appropriate nursing care. Pediatric (1-12years) Adolescents (12 - 18 years) Adult (18-65 years) Older Adult (older than 65)

J. EXPERIENCE WITH AGE GROUPS

1. Calculate body weight to verify correct dosing of medication 2. Assess immunization status for pediatric, and adolescent 3. Set age-appropriate short-term and long-term goals in care planning 4. Provide age-appropriate education, considering possible vision and hearing impairment for Older than 65years.

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________________________________________________________________________ The information I have given is true and accurate to the best of my knowledge. I hereby authorize Rx Med Staff, LLC to release this Psychiatric RN Skills Checklist to Client facilities of Rx Med Staff, LLC in consideration of my assignment to work at those facilities.

_________________________________________ Signature

________________________ Date

Psych RN Skills Checklist Page 3 of 3


OMB No. 1115-0136

U.S. Department of Justice Immigration and Naturalization Service

Employment Eligibility Verification INSTRUCTIONS

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THIS FORM.

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the U.S.) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination.

Section 1 - Employee.

All employees, citizens and noncitizens, hired after November 6, 1986, must complete Section 1 of this form at the time of hire, which is the actual beginning of employment. The employer is responsible for ensuring that Section 1 is timely and properly completed.

Preparer/Translator Certification. The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his/her own. However, the employee must still sign Section 1.

Section 2 - Employer. For the purpose of completing this form, the term "employer" includes those recruiters and referrers for a fee who are agricultural associations, agricultural employers or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment eligibility within three (3) business days of the date employment begins. If employees are authorized to work, but are unable to present the required document(s) within three business days, they must present a receipt for the application of the document(s) within three business days and the actual document(s) within ninety (90) days. However, if employers hire individuals for a duration of less than three business days, Section 2 must be completed at the time employment begins. Employers must record: 1) document title; 2) issuing authority; 3) document number, 4) expiration date, if any; and 5) the date employment begins. Employers must sign and date the certification. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. These photocopies may only be used for the verification process and must be retained with the I-9. However, employers are still responsible for completing the I-9.

Section 3 - Updating and Reverification. Employers must complete Section 3 when updating and/or reverifying the I-9. Employers must reverify employment eligibility of their employees on or before the expiration date recorded in Section 1. Employers CANNOT specify which document(s) they will accept from an employee. If an employee's name has changed at the time this form is being updated/ reverified, complete Block A. If an employee is rehired within three (3) years of the date this form was originally completed and the employee is still eligible to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

If an employee is rehired within three (3) years of the date this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B and: examine any document that reflects that the employee is authorized to work in the U.S. (see List A or C), record the document title, document number and expiration date (if any) in Block C, and complete the signature block. Photocopying and Retaining Form I-9. A blank I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed I-9s for three (3) years after the date of hire or one (1) year after the date employment ends, whichever is later. For more detailed information, you may refer to the INS Handbook for Employers, (Form M-274). You may obtain the handbook at your local INS office. Privacy Act Notice. The authority for collecting this information is the Immigration Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a). This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States. This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by officials of the U.S. Immigration and Naturalization Service, the Department of Labor and the Office of Special Counsel for Immigration Related Unfair Employment Practices. Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986. Reporting Burden. We try to create forms and instructions that are accurate, can be easily understood and which impose the least possible burden on you to provide us with information. Often this is difficult because some immigration laws are very complex. Accordingly, the reporting burden for this collection of information is computed as follows: 1) learning about this form, 5 minutes; 2) completing the form, 5 minutes; and 3) assembling and filing (recordkeeping) the form, 5 minutes, for an average of 15 minutes per response. If you have comments regarding the accuracy of this burden estimate, or suggestions for making this form simpler, you can write to the Immigration and Naturalization Service, HQPDI, 425 I Street, N.W., Room 4034, Washington, DC 20536. OMB No. 1115-0136.

EMPLOYERS MUST RETAIN COMPLETED FORM I-9 PLEASE DO NOT MAIL COMPLETED FORM I-9 TO INS

Form I-9 (Rev. 11-21-91)N


OMB No. 1115-0136

U.S. Department of Justice Immigration and Naturalization Service

Employment Eligibility Verification

Please read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work eligible individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because of a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Verification. Print Name:

Last

To be completed and signed by employee at the time employment begins.

First

Address (Street Name and Number) State

City

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

Middle Initial

Maiden Name

Apt. #

Date of Birth (month/day/year)

Zip Code

Social Security #

I attest, under penalty of perjury, that I am (check one of the following): A citizen or national of the United States A Lawful Permanent Resident (Alien # A / / An alien authorized to work until (Alien # or Admission #) Date (month/day/year)

Employee's Signature

Preparer and/or Translator Certification.

(To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Preparer's/Translator's Signature

Print Name

Address (Street Name and Number, City, State, Zip Code)

Date (month/day/year)

Section 2. Employer Review and Verification. To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number and expiration date, if any, of the document(s)

List A

List B

OR

List C

AND

Document title: Issuing authority: Document #: Expiration Date (if any):

/

/

/

/

/

/

/

/

Document #: Expiration Date (if any):

CERTIFICATION - I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the and that to the best of my knowledge the employee / / employee began employment on (month/day/year) is eligible to work in the United States. (State employment agencies may omit the date the employee began employment.) Signature of Employer or Authorized Representative Business or Organization Name

Print Name

Title Date (month/day/year)

Address (Street Name and Number, City, State, Zip Code)

Section 3. Updating and Reverification.

To be completed and signed by employer.

A. New Name (if applicable)

B. Date of rehire (month/day/year) (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment eligibility. Document Title:

Document #:

Expiration Date (if any):

/

/

l attest, under penalty of perjury, that to the best of my knowledge, this employee is eligible to work in the United States, and if the employee presented document(s), the document(s) l have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Date (month/day/year) Form I-9 (Rev. 11-21-91)N Page 2


LISTS OF ACCEPTABLE DOCUMENTS LIST A Documents that Establish Both Identity and Employment

Eligibility

Documents that Establish Identity

OR

1. U.S. Passport (unexpired or expired) 2. Certificate of U.S. Citizenship (INS Form N-560 or N-561) 3. Certificate of Naturalization (INS Form N-550 or N-570)

4. Unexpired foreign passport, with I-551 stamp or attached INS Form I-94 indicating unexpired employment authorization 5.

LIST C

LIST B

Permanent Resident Card or Alien Registration Receipt Card with photograph (INS Form I-151 or I-551)

6. Unexpired Temporary Resident Card (INS Form I-688) 7. Unexpired Employment Authorization Card (INS Form I-688A) 8. Unexpired Reentry Permit (INS Form I-327) 9. Unexpired Refugee Travel Document (INS Form I-571) 10. Unexpired Employment Authorization Document issued by the INS which contains a photograph (INS Form I-688B)

AND

1. Driver's license or ID card issued by a state or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color and address 3. School ID card with a photograph 4. Voter's registration card

Documents that Establish Employment Eligibility

1. U.S. social security card issued by the Social Security Administration (other than a card stating it is not valid for employment)

2. Certification of Birth Abroad issued by the Department of State (Form FS-545 or Form DS-1350)

3. Original or certified copy of a birth certificate issued by a state, county, municipal authority or outlying possession of the United States bearing an official seal

5. U.S. Military card or draft record 6.

Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above:

10. School record or report card 11. Clinic, doctor or hospital record

4. Native American tribal document

5. U.S. Citizen ID Card (INS Form I-197)

6. ID Card for use of Resident Citizen in the United States (INS Form I-179)

7. Unexpired employment authorization document issued by the INS (other than those listed under List A)

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274) Form I-9 (Rev. 10/4/00)Y Page 3


Rx Med Staff, LLC 502 Granberry Humble, Texas 77338 Office: (832) 527-0771 Fax: (281) 596-2714 7214 www.rxmedstaff.com Hospital/Client’s name Employee’s name Social Security # Area date

Dept# time start

time end

break

reg hrs

over time

client approved

Sun

Mon

Tue

Wed

Thu Fri Sa

Total hours to nearest ¼ hrs

I certify that the hours shown above are correct and performed satisfactorily. Employee signature:

date:

I certify that the hours shown above are the accurate hours worked and verified by client or by an authorized representative.

Signatue of authorized personnel of Facility ONLY

date:


2 TLS, have you transmitted all R text files for this cycle update?

I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS FORM W-4, PAGE 1 of 2 MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PAPER: WHITE WRITING, SUB. 20. FLAT SIZE: 216mm (81⁄2 ") x 279mm (11") PERFORATE: 179mm (67⁄8 ") FROM TOP TRIM

Date

Action

Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Because your tax situation may change, you may want to refigure your withholding each year. Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2006 expires February 16, 2007. See Pub. 505, Tax Withholding and Estimated Tax. Note. You cannot claim exemption from withholding if (a) your income exceeds $850 and includes more than $300 of unearned income (for example, interest and dividends) and (b) another person can claim you as a dependent on their tax return. Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-

earner/two-job situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. Head of household. Generally, you may claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See line E below. Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 919, How Do I Adjust My Tax Withholding, for information on converting your other credits into withholding allowances. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax.

Signature

O.K. to print

PRINTS: HEAD to HEAD INK: BLACK

Revised proofs requested

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form W-4 (2006)

Date

Two earners/two jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. Nonresident alien. If you are a nonresident alien, see the Instructions for Form 8233 before completing this Form W-4. Check your withholding. After your Form W-4 takes effect, use Pub. 919 to see how the dollar amount you are having withheld compares to your projected total tax for 2006. See Pub. 919, especially if your earnings exceed $130,000 (Single) or $180,000 (Married). Recent name change? If your name on line 1 differs from that shown on your social security card, call 1-800-772-1213 to initiate a name change and obtain a social security card showing your correct name.

Personal Allowances Worksheet (Keep for your records.)

A

Enter “1” for yourself if no one else can claim you as a dependent ● You are single and have only one job; or B Enter “1” if: ● You are married, have only one job, and your spouse does not work; or ● Your wages from a second job or your spouse’s wages (or the total of both) are $1,000 or less.

A

B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or C more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) D D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return E E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) F F Enter “1” if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit (Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit): ● If your total income will be less than $55,000 ($82,000 if married), enter “2” for each eligible child. ● If your total income will be between $55,000 and $84,000 ($82,000 and $119,000 if married), enter “1” for each eligible G child plus “1” additional if you have four or more eligible children. 䊳 H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H ● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions For accuracy, and Adjustments Worksheet on page 2. complete all ● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs worksheets exceed $35,000 ($25,000 if married) see the Two-Earner/Two-Job Worksheet on page 2 to avoid having too little tax withheld. that apply. ● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Cut here and give Form W-4 to your employer. Keep the top part for your records. Form

W-4

Department of the Treasury Internal Revenue Service

1

Whether you are entitled to claim a certain number of allowances or exemption from withholding is subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

Type or print your first name and middle initial.

Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

5 6 7

OMB No. 1545-0074

Employee’s Withholding Allowance Certificate 2

2006

Your social security number

Married, but withhold at higher Single rate. 3 Single Married Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box. 4

If your last name differs from that shown on your social security card, check here. You must call 1-800-772-1213 for a new card. 䊳

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 6 Additional amount, if any, you want withheld from each paycheck I claim exemption from withholding for 2006, and I certify that I meet both of the following conditions for exemption. ● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and ● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability. 䊳 If you meet both conditions, write “Exempt” here 7

$

Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (Form is not valid unless you sign it.) 8

Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)

For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Date 9

Office code (optional)

Cat. No. 10220Q

10

Employer identification number (EIN)

Form

W-4

(2006)


2 I.R.S. SPECIFICATIONS TO BE REMOVED BEFORE PRINTING INSTRUCTIONS TO PRINTERS FORM W-4, PAGE 2 of 2 MARGINS: TOP 13mm (1⁄2 "), CENTER SIDES. PRINTS: HEAD to HEAD PAPER: WHITE WRITING, SUB. 20. INK: BLACK FLAT SIZE: 216mm (81⁄2 ") x 279mm (11") PERFORATE: See Page 1 Specifications DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form W-4 (2006)

Page

2

Deductions and Adjustments Worksheet Note. Use this worksheet only if you plan to itemize deductions, claim certain credits, or claim adjustments to income on your 2006 tax return. 1 Enter an estimate of your 2006 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions. (For 2006, you may have to reduce your itemized deductions if your income 1 $ is over $150,500 ($75,250 if married filing separately). See Worksheet 3 in Pub. 919 for details.) $10,300 if married filing jointly or qualifying widow(er) 2 Enter: $ 7,550 if head of household 2 $ $ 5,150 if single or married filing separately 3 Subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” 3 $ 4 Enter an estimate of your 2006 adjustments to income, including alimony, deductible IRA contributions, and student loan interest 4 $ 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from Worksheet 7 in Pub. 919) 5 $ 6 Enter an estimate of your 2006 nonwage income (such as dividends or interest) 6 $ 7 Subtract line 6 from line 5. Enter the result, but not less than “-0-” 7 $ 8 Divide the amount on line 7 by $3,300 and enter the result here. Drop any fraction 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 9 10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earner/Two-Job Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earner/Two-Job Worksheet (See Two earners/two jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here

1 2

3

If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet 3 Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4–9 below to calculate the additional withholding amount necessary to avoid a year-end tax bill. 4 5 6 7 8 9

Enter the number from line 2 of this worksheet 4 Enter the number from line 1 of this worksheet 5 Subtract line 5 from line 4 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed Divide line 8 by the number of pay periods remaining in 2006. For example, divide by 26 if you are paid every two weeks and you complete this form in December 2005. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

6 7 8

$ $

9

$

Table 1: Two-Earner/Two-Job Worksheet Married Filing Jointly If wages from HIGHEST paying job are— $0 - $42,000

$42,001 and over

AND, wages from LOWEST paying job are— $0 - $4,500 4,501 9,000 9,001 - 18,000 18,001 and over $0 4,501 9,001 18,001 22,001 26,001

-

All Others

Enter on If wages from HIGHEST line 2 above paying job are— $42,001 and over 0 1 2 3

$4,500 9,000 18,000 22,000 26,000 32,000

0 1 2 3 4 5

AND, wages from LOWEST paying job are— 32,001 - 38,000 38,001 - 46,000 46,001 - 55,000 55,001 - 60,000 60,001 - 65,000 65,001 - 75,000 75,001 - 95,000 95,001 - 105,000 105,001 - 120,000 120,001 and over

Enter on line 2 above 6 7 8 9 10 11 12 13 14 15

If wages from LOWEST paying job are— $0 - $6,000 6,001 - 12,000 12,001 - 19,000 19,001 - 26,000 26,001 - 35,000 35,001 - 50,000 50,001 - 65,000 65,001 - 80,000 80,001 - 90,000 90,001 - 120,000 120,001 and over

Enter on line 2 above 0 1 2 3 4 5 6 7 8 9 10

Table 2: Two-Earner/Two-Job Worksheet Married Filing Jointly If wages from HIGHEST paying job are— $0 - $60,000 60,001 - 115,000 115,001 - 165,000 165,001 - 290,000 290,001 and over

All Others Enter on line 7 above $500 830 920 1,090 1,160

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. The Internal Revenue Code requires this information under sections 3402(f)(2)(A) and 6109 and their regulations. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may also subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, to cities, states, and the District of Columbia for use in administering their tax laws, and using it in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to

If wages from HIGHEST paying job are— $0 - $30,000 30,001 - 75,000 75,001 - 145,000 145,001 - 330,000 330,001 and over

Enter on line 7 above $500 830 920 1,090 1,160

the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return. If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.


Rx Med Staff,LLC

Medication Exam for Nurses Name____________________________________ Date___________________ 1. The order is for 5mg. The label reads gr. 1/12 per tablet. You would give _________ tablet(s). 2. The order is for 30ml. You would give ___________ tablespoon (s). 3. The order is for 60mg. The label reads 80mg/2ml. You would give _______ml(s). 4. The order is for 250mg. The label reads 0.5gm per tablet. You would give _______ tablet (s). 5. The order is for gr 1/200. The label reads gr. 1/100 per 2 ml . You would give _______ ml(s). 6. The order is for 1,000ml of NS to be infused at 125ml/hr. You would infuse the solution for ___________ hour(s). 7. The order is for 100ml/hr of IV solution. The drop factor of the IV tubing is 15gtts/ml. You would infuse the solution at _______ gtts/min. 8. The order is 10,000 units of a medication in 1 liter to be infused at 1,000 units/hr. You would infuse __________ ml (s) per hour. 9. The order is for 3,000ml of LR to be infused over 24 hour period. The drop factor of the IV tubing is 10gtts/min. You would infuse_________gtts/min. 10.

The physician prescribed Elixir of Lanoxin (digoxin) 125mcg. The bottle is labeled 0.05mg/ml The nurse should give ________ ml (s).

11.

The physician ordered Kanamycin Sulfate (Kantrex) IM injection 15mg/kg/day in two divided doses for an infant who weighs 11lbs. The available vial is labeled Kantrex Pediatric Injection 75mg/2ml. • Based on the weight in Kg this infant should receive_____________mg/day • This should be divided into__________mg every 12 hours • The nurse should administer _________ ml (s)


Rx Med Staff, LLC 12.

Laboratory values have indicated an overdosage of Coumadin in a patient. What drug is the antidote? A. Vitamin K B. Protamine Sulfate C. Epogen

13.

During administration of Heparin via an IV drip , which of the following labs needs to be monitored frequently as every 6hrs? A. Partial thromboplastin time (PTT) B. Prothrombin time (PT) C. Serum fibrinogen

14.

Symptoms of Digitalis Toxicity include: A. N/V, visual disturbances B. Leg cramps, anorexia, drowsiness C. abdominal pain, constipation, anorexia

15.

The physician has ordered a Heparin Bolus of 5,000 units IV followed by a Heparin drip at 1,000 units per hour. The standard mixture of Heparin is 25,000 units/500 D5W. H ow many ml/hr should the pump be set to administer the Heparin drip.__________ml (s) /hr.

16.

A new medication, X disodium, comes as a powder which must be reconstituted as follows:For IV use: Add 24ml of sterile water for injection,USP. Each 2.5ml of resulting solution contains 500 mg of X. Prior to administration , dilute further to desired volume with an appropriate IV solution. How many ml must be injected into 100ml IV bag of NS to equal 1.5 Gm of X? ___________ml(s)

17.

A procainamide drip is ordered for 2mg/min. The standard mixture is 2g in 500ml. How many ml/hr should the IV pump be set?_________ml/hr

18.

A patient is receiving Humulin N 35 units each morning at 0730. At which time listed below is this person most at risk of a hypoglycemia reaction? A. 9 AM B. 11 AM C. 3PM

19.

A unit of Packed RBC approximately 240ml is to be administered over 4 hours. The blood tubing has a drop factor of 10gtt/ml. Calculate the drip rate in gtt/min in order to administer the blood over 4hours.________________gtt/min.

20.

A hypokalemic patient is receiving an infusion of NS containing 60meq potassium chloride at 100ml/hr. Which of the following is the most appropriate for the patient? A. deep tendon reflexes checked every 1 hr B. serum potassium level every 1 hr C. continuous cardiac monitoring


Psych Application RN