Score the clients level of stability:

0. client condition is chronic/stable/predictable
1. client condition has minimal potential for change
2. client condition has moderate potential for change
3. client condition is unstable/acute/strong potential for change

Score the UAP competence in completing delegated nursing care activities in the defined client population

0. UAP- expert in activities to be delegated in defined population
1. UAP- experienced in activities to be delegated in defined population
2. UAP- experienced in activities but not in defined population
3. UAP-novice in performing activities and in defined population

Score the licensed nurse’s competence in relation to both knowledge of providing nursing care to a defined population and competence in implementation of the delegation process:

0. Expert in the knowledge of nursing needs/activities of defined client population and expert in the delegation process
1. Either expert in knowledge of needs/activities of defined client population and competent in delegation or experienced in the needs/activities of defined client population and expert in the delegation process
2. Experienced in the knowledge of needs/activities of defined client population and competent in the delegation process
3. Either experienced in the knowledge of needs/activities defined client population and competent in the delegation process
4. Either experienced in the knowledge of needs/activities of defined client population or competent in the delegation process
5. Novice in knowledge of defined population and novice in delegation

Score the potential level of risk the nursing care activity has for the client(risk probability of suffering harm):

0. None
1. Low
2. Medium
3. High

Score based on how often the UAP has performed the specific nursing care activity:

0. Performed at least daily
1. Performed at least weekly
2. Performed at least monthly
3. Performed less than monthly
4. Never performed

Score the decision-making needed, related to the specific nursing care activity, client(both cognitive and physical status) and client situation:

0 Does not require decision making

Minimal level of decision making

Moderate level of decision making

Score the client’s level of assistance needed for self-care activities:

0. No assistance
1. Limited assistance
2. Extensive assistance
3. 3. Total care or constant attendance