Chapter 4723-4 of the Ohio Administrative Code is one of 19 chapters that establishes rules for the practice of nursing in in the state of Ohio, including the minimal acceptable standards for safe and effective nursing practice by registered nurses, licensed practical nurses, and advanced practiced registered nurses; certified nurse-midwifes, certified nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists.

Chapter 4723-4 consists of eight sections, including:

• 01: General Information
• 03: Standards Relating to Competent Practice as a Registered Nurse
• 04: Standards Relating to Competent Practice as a Licensed Practical Nurse
• 05: Standards Relating to Competent Practice as a Certified Nurse-Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist, Or Clinical Nurse Specialist
• 06: Standards of Nursing Practice Promoting Patient Safety
• 07: Standards for Applying the Nursing Process as a Registered Nurse
• 08: Standards for Applying the Nursing Process as a Licensed Practical Nurse
• 09: Specialty Certification

Chapter 4723-4 – Ohio Administrative Code | Ohio Laws

4723-4-01: General Information

4723-4 of the Ohio Laws and administrative rules establishes the minimal acceptable standards of safe and effective nursing practice for a registered nurse, licensed practical nurse, an advanced practice registered nurse; certified nurse-midwifes, certified nurse practitioners, certified registered nurse anesthetists, or clinical nurse specialists in any setting.

The following definitions apply to this chapter:

Certified Nurse Midwife	A RN who holds a current valid advanced practice registered nurse license issued by the board.
Certified Nurse Practitioner	A RN who holds a current valid advanced practice registered nurse license issued by the board.
Certified Registered Nurse Anesthetist	A registered nurse who holds a current valid advanced practice registered nurse license issued by the board.
Clinical Judgment	The application of the nurse’s knowledge and reasoning to make decisions about patient care.
Clinical Nurse Specialist	A RN who holds a current valid advanced practice registered nurse license issued by the board.
Direction	Communicating a plan of care to a licensed practical nurse. Direction by an RN does not mean that the RN is supervising the LPN.
Licensed Nurse	A RN or an LPN who holds a current valid license to practice nursing in Ohio.
Nursing Diagnosis	The identification of a patient’s needs or problems that are responsive to nursing intervention.
Patient	An individual, group, or a community that is the recipient of nursing care.

Rule 4723-4-01 – Ohio Administrative Code | Ohio Laws

4723-4-03: Standards Relating to Competent Practice as a Registered Nurse

An RN must provide care that is within the scope of their practice, and must remain knowledgeable of the duties, responsibilities, and remain accountable for safe nursing practice by:

• Having consistent nursing performance.
• Recognizing, consulting, and intervening when a complication arises.

The RN must implement an order for a patient, unless the order appears to be:

• Contraindicated by other documented information.
• Inaccurate.
• Not current or valid.
• Not properly authorized.
• Potentially harmful to a patient.

When clarifying an order, the registered nurse must consult with the licensed provider, notify them when a medication or treatment is not followed, document who was notified, and any actions to assure patient safety.

A registered nurse may only provide nursing care beyond basic nursing preparation when:

• The nurse obtains the appropriate education.
• The nurse demonstrates knowledge, skills, and abilities necessary to provide nursing care.
• The nurse has documentation meeting board requirements.
• The nursing care does not involve anything that is prohibited by law.

When an RN provides direction to an LPN, they must first assess:

• The patient’s condition.
• The type of care the patient needs.
• The complexity of the care needed.
• The training, skill, and knowledge of the LPN who will perform the duties.

An RN must maintain the confidentiality of patient information and should only communicate patient information with other members of the patient’s health care team. To the maximum extent of the law, the RN must not disclose any patient healthcare information without the patient’s consent. Only in accordance with an authorized law or rule can an RN disclose patient healthcare information without the patient’s consent.

Case Reflection

Justine is a registered nurse who is assigned to work in the medical surgical (MedSurg) ward. She just received a report on a new patient, Mrs. Roberts, who is being admitted after having a hysterectomy. Mrs. Roberts is transferring from the recovery area to the MedSurg ward. During the transfer report, the nurse said that Mrs. Roberts did not have any pain in the recovery area and did not request any pain medication. Upon arrival at the MedSurg ward, Justine assessed Mrs. Roberts, and Mrs. Roberts said that her pain level was 6/10 at the surgical site. Justine reviewed the order for pain medication and noted that hydromorphone (Dilaudid) 40 mg intravenous (IV) is ordered every four hours as needed for pain. Justine immediately recognizes the error in the medication dose and decides not to follow the order. What should Justine do once that decision is made? How can she correct the order? Who should Justine notify regarding the unsafe dose of pain medication, and what should she document?

 4723-4-04: Standards Relating to Competent Practice as a Licensed Practical Nurse

• An LPN must function within the scope of practice of nursing for an LPN.
• An LPN must demonstrate competence and accountability in all areas of practice, including:
  • Consistent performance of nursing care.
  • Recognize and intervene when a complication arises.

• An LPN may provide nursing care that is beyond basic preparation provided:
  • The nurse obtains education that is relative to the nursing care to be provided.
  • The nurse demonstrates knowledge, skills, and abilities necessary to perform nursing care.
  • The nurse maintains documentation satisfactory to the board of meeting the requirements.
  • The nurse has a current valid order or direction from an individual who is authorized to practice in Ohio and is acting within the scope of the individual’s professional practice.
  • Nursing care does not include a procedure that is prohibited.
• In a timely manner, an LPN must:
  • Implement any order or direction for a patient unless the LPN believes the order or direction is:
    • Inaccurate.
    • Not properly authorized.
    • Not valid.
    • Harmful, or potentially harmful to a patient.
    • Contraindicated by other documented information.
  • Clarify any order or direction for a patient when the LPN believes the order or direction is:
    • Inaccurate.
    • Not properly authorized.
    • Not current or valid.
    • Harmful, or potentially harmful to a patient.
    • Contraindicated by other documented information.
• When clarifying an order or direction, the LPN must:
  • Consult with an appropriate licensed practitioner or directing registered nurse.
  • Notify the ordering practitioner or directing RN when the LPN makes the decision not to follow the order or administer the medication treatment as prescribed.
  • Document that the practitioner or directing RN was notified of the decision not to follow the order or administer the medication treatment as prescribed.
  • Take any other action needed to assure the safety of the patient.
• In a timely manner, an LPN must report to and consult with other members of the health care team and make referrals as necessary.
• An LPN must maintain confidentiality of patient information while practicing nursing and only communicate patient information to other members of the health care team for health care purposes.
• An LPN must only access patient information for the purpose of patient care.
• An LPN must not disseminate patient information for purposes other than patient care, including social media, texting, emailing or any other form of communication.
• Identifiable patient health care information must not be disclosed by an LPN unless the patient has consented to the disclosure of identifiable patient health care information, except in limited circumstances including authorized law, rule, or other recognized legal authority.
• When an LPN is directed to observe, instruct, or evaluate the performance of a nursing task, the LPN must use acceptable nursing standards and communicate information that is consistent with acceptable standards of safe nursing care.

Rule 4723-4-04 – Ohio Administrative Code | Ohio Laws

4723-4-05: Standards Relating to Competent Practice as a Certified Nurse-Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist, or Clinical Nurse Specialist

 A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist must:

• Function within the scope of practice of nursing for a registered nurse.
• Function within the nurse’s applicable scope of practice.
• If authorized by Ohio law to prescribe, practice according to the Ohio laws and administrative rules.

A certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist may provide care after:

• The nurse obtains education from a recognized body of knowledge.
• The nurse demonstrates knowledge, skills, and abilities necessary to provide nursing care.
• The nurse maintains documentation evidence of meeting the requirements.

When the practice of a certified nurse-midwife, certified nurse practitioner, certified registered nurse anesthetist, or clinical nurse specialist is evaluated, the evaluation must be provided by a licensed physician or podiatrist, or an advanced practice registered nurse with the same license designation as the nurse being evaluated.

Rule 4723-4-05 – Ohio Administrative Code | Ohio Laws

4723-4-06: Standards of Nursing Practice Promoting Patient Safety

• All licensed nurses must display their title or initials whenever providing care to a patient. A licensed nurse must also provide their title or initials when telecommunicating to a patient or a healthcare provider on the patient’s behalf.
• In a timely manner, a licensed nurse must accurately report and document nursing assessments or observations, the care provided, and the patient’s response to care, and must not falsify or conceal any part of the patient’s record.
• The licensed nurse must implement a safe environment for the patient, including:
  • Providing privacy during examination and treatment.
  • Treat the patient with courtesy and respect.
  • Not engage in behavior to obtain personal gain at the patient’s expense, including getting involved in patient’s personal relationships or financial matters.
  • Not engage in any verbal or physical behavior deemed to be sexual in nature, as a patient is always presumed to be incapable of giving informed consent to such behaviors.

Only an RN can supervise or evaluate another nurse, however, outside of nursing practice, a non-nursing supervisor may evaluate a nurse employee. Supervision by an RN does not require that the RN be present on-site, but the RN must conduct enough on-site visits to evaluate another nurse’s performance.

A licensed nurse must not make or submit any false, misleading, or deceptive statements, or information to:

• The board or any representative of the board.
• Current employers.
• Prospective employers.
• Any organization that employs the nurse, including a temporary, agency, or locum tenens assignments.
• Other members of the patient’s health care team.
• Law enforcement personnel.

Rule 4723-4-06 – Ohio Administrative Code | Ohio Laws

Case Reflection

Michelle is an LPN in the emergency room. She is assigned to Mr. Campbell, a police officer who was involved in a car accident while on duty. Michelle’s colleagues are curious regarding the circumstances of the accident and question how bad Mr. Campbell’s injuries are, and if he was ‘chasing a bad guy.’ Michelle proceeds to tell her colleagues what she knows about the accident and Mr. Campbell’s injuries, and then says, “It’ll probably be on the news tonight.” Michelle then goes to the bedside of Mr. Campbell and begins to perform an assessment without closing the drape for privacy. One of Michelle’s colleague’s comments on Mr. Campbell’s physical appearance, saying “He must work out a lot. Look how broad his chest is. I bet he has washboard abs.”  What standards of nursing practice and promoting patient safety do you recognize as not being followed? Did Michelle promote a safe environment for her patient? What would you do in the same situation?

 

4723-4-07: Standards for Applying the Nursing Process as a Registered Nurse

A nurse must apply the nursing process when practicing nursing. The nursing process is cyclical and requires the nurse to respond to a patient’s changing status throughout the process. This includes:

• Assessing the health status.
• Collecting subjective and objective data and documenting such data.
• Establish, accept, or modify a nursing diagnosis and interventions.
• Report findings and nursing diagnosis to other team members.
• Develop, establish, maintain, or modify the nursing plan of care and communicate it with other team members.
• Implement valid orders within the nurse’s scope of practice.
• Delegate nursing tasks, including medication administration to the appropriate personnel.
• Evaluate, document, and report the patient’s response to interventions and progress to expected outcomes.
• Reassess and update the nursing plan, as necessary.

Rule 4723-4-07 – Ohio Administrative Code | Ohio Laws

4723-4-08: Standards for Applying the Nursing Process as a Licensed Practical Nurse

The LPN shall contribute to the nursing process when practicing nursing. The nursing process is cyclical and requires the nurse to respond to a patient’s changing status throughout the process. The LPN must maintain the following standards during the nursing process:

• Contribute to the assessment of a patient’s health status by collecting and documenting subjective and objective data and reporting such data to the registered nurse or other members of the healthcare team.
  • Contribute to the development, maintenance, or modification of the nursing care plan and communicate it with other healthcare team members.
  • Administer medications and treatments prescribed.
  • Provide basic nursing care and collaborate with other team members.
  • Delegate nursing tasks as directed, including medication administration.
  • Contribute to the evaluation of a patient’s response to nursing interventions and document and communicate such responses to member of the healthcare team.
  • Contribute to the reassessment of the patient and update the nursing plan, as necessary.

Rule 4723-4-08 – Ohio Administrative Code | Ohio Laws

Case Reflection

Michael, a registered nurse, and Lindsey a licensed practical nurse, are working together as a team on the telemetry unit. Michael and Lindsey work collaboratively to divide the work of their assigned patients. Michael informs Lindsey that he will conduct and document the physical assessments on all the patients. He delegates the tasks of obtaining vital signs, administering medications, and performing glucose checks to Lindsey.

Lindsey is a new nurse to the telemetry unit, but thus far, she has not had any difficulties working within a team. She obtains vital signs and administers the medications without difficulty and as prescribed, however, she has not received training on the glucometer and is unfamiliar with how to use it. She informs Michael of her inability to use the glucometer. Michael hurriedly performs the glucose check on one of the patients, and based on the results, delegates Lindsey to administer insulin according to the sliding scale that is ordered. He does not inform her however, that the blood sugar must be rechecked after the sliding scale dose is administered, as stipulated in the written orders. Because Lindsey does not have the appropriate training, she is unable to recheck the glucose, and because Michael delegated the task of administering the sliding scale dose of insulin, he never rechecked the blood glucose. What standards of the nursing process were omitted in this scenario? What should have been reported? Given the situation, what would you do differently?

4723-4-09: Specialty Certification

 A registered nurse with a current, valid license to practice nursing in Ohio may use a title or initials denoting specialty certification in a particular area of specialty in nursing that has been granted by a national certifying organization. The registered nurse may use initials following the title “Registered Nurse” or the initials “RN”.

No person can use any initials or title that implies they have specialty certification unless that person has been granted a specialty certification title in nursing by a national certifying organization.

Rule 4723-4-09 – Ohio Administrative Code | Ohio Laws