# COMAR Title 10 — Maryland Department of Health ## Subtitle 27 — Board of Nursing ### Chapter 09 — Standards of Practice for Registered Nurses **Authority:** Health-General Article, §4-403; Health Occupations Article, §§8-205 and 8-316, Annotated Code of Maryland **Administrative History:** Effective date: February 20, 1989 (16:3 Md. R. 343) **Administrative History:** Regulation .03 amended effective October 25, 1993 (20:21 Md. R. 1654) **Administrative History:** Regulations .01—.03 repealed and new Regulations .01—.03 adopted effective April 3, 2000 (27:6 Md. R. 642) **Administrative History:** Regulation .01B amended effective July 2, 2018 (45:13 Md. R. 667) **Administrative History:** Regulation .02G adopted effective October 13, 2025 (52:20 Md. R. 1002) **Administrative History:** Regulation .04 adopted effective March 17, 2014 (41:5 Md. R. 346) #### Regulation .01 Definitions. *COMAR 10.27.09.01* A. In this chapter, the following terms have the meanings indicated. B. Terms Defined. (1) “Accountability” means being answerable for the actions of self and others. (2) “Aggregate” means the sum total of nursing care the client received. (3) “Assessment” means a systematic, dynamic process by which the nurse, through interaction with the client, family, significant others, and other health care providers, collects and analyzes data. (4) “Assign” means the transfer of responsibility from one nurse to another with each nurse having the legal authority to perform the function as permitted by the licensee's scope of practice. (5) “Client” means an individual, family, group, or community under the licensee's direct or indirect care. (6) “Continuity of care” means an interdisciplinary process that: (a) Includes the client, family, and significant other in the development and communication of a coordinated plan of care; and (b) Based on changing needs and available resources, facilitates the client's: (i) Care within a setting, and (ii) Transition between settings. (7) “Criteria” means relevant, measurable indicators of the standards of registered nurse practice. (8) “Delegate” means the registered nurse: (a) Invests authority to act on behalf of the registered nurse to an unlicensed person; (b) Authorizes the unlicensed person to augment and supplement the care the registered nurse provides; and (c) Retains the accountability and responsibility for the delegated act. (9) “Evaluation” means the review and analysis of the extent to which the assessment, nursing diagnosis, planning, and implementation is effective in resolving the client's health problems or progress toward the attainment of expected outcomes. (10) Health Care Providers. (a) “Health care provider” means an individual with special expertise who provides health care services or assistance to clients. (b) “Health care provider” includes: (i) Nurses; (ii) Physicians; (iii) Psychologists; (iv) Social workers; (v) Nutritionists/dietitians; and (vi) Various therapists. (11) “Health care team” means a group of individuals, which includes health care providers and unlicensed personnel, working in collaboration with the client, family, and significant others to achieve identified outcomes. (12) Health Status Data. (a) “Health status data” means information obtained through nursing assessment of the client. (b) “Health status data” includes but is not limited to: (i) Growth and development; (ii) Biophysical status; (iii) Emotional status; (iv) Cultural, religious, and socioeconomic background; (v) Activities of daily living and instrumental activities of daily living; (vi) Patterns of coping; (vii) Interaction patterns; (viii) Client perception of and degree of satisfaction with health status; (ix) Client health goals; (x) Physical, social, emotional, and ecological environments; and (xi) Access to and availability of human and material resources. (13) “Implementation” means the process of performing, delegating, assigning, supervising, and coordinating interventions. (14) “Instrumental activities of daily living” means home management skills such as shopping for food and personal items, preparing meals, or handling money. (15) “Multistate licensure privilege” has the meaning set forth in COMAR 10.27.01.01B. (16) “Nursing diagnosis” means a description of the actual or potential, overt or covert health problems which registered nurses are licensed to treat. (17) “Outcomes” means measurable, expected, client-focused goals which translate into observable behaviors. (18) “Plan of care” means designing methods to solve identified problems and to attain outcomes by means of establishing priorities, setting goals, and defining interventions. (19) “Process” means the delivery of care and the fulfillment of the practice standards. (20) “Quality of care” means the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. (21) “Recipients of nursing care” means individuals, families, groups, communities, or populations. (22) “Registered nurse (RN)” means an individual who: (a) Is licensed by the Board to practice registered nursing; or (b) Has a multistate licensure privilege to practice registered nursing. (23) “Responsibility” means the obligation and duty to perform. (24) “Scientific principles” means a fundamental belief or reason for action derived from an organized system of study. (25) “Standards of care” means a minimum level of competent nursing practice demonstrated through assessment, analysis, formulation of nursing diagnosis, outcome identification, planning, implementation, and evaluation. (26) Standards of Registered Nurse Practice. (a) “Standards of registered nurse practice” means the minimum criteria the registered nurse shall adhere to in the practice of registered nursing. (b) “Standards of registered nurse practice” includes both standards of care and standards of professional performance. (27) Standards of Professional Performance. (a) “Standards of professional performance” means a competent level of behavior in the professional role. (b) “Standards of professional performance” includes activities related to: (i) Quality of care; (ii) Performance appraisal; (iii) Education; (iv) Collegiality; (v) Ethics; (vi) Collaboration; (vii) Research; (viii) Resource utilization; (ix) Assignment; (x) Delegation and supervision; and (xi) Refusal. (28) “Structure” means: (a) The environment in which care is provided; and (b) Resources available to provide care including but not limited to finances, staffing, supplies, equipment, and medical records. (29) “Technology assessment” means a review of drugs, devices, procedures, and systems in relationship to their safety, effectiveness, and economic and social impact. #### Regulation .02 Standards of Care. *COMAR 10.27.09.02* A. Assessment. (1) The RN shall collect client health data. (2) Measurement Criteria. (a) Data collection shall involve the client, family, significant others, other members of the health care team, and the health record, when appropriate. (b) Data may include the following dimensions: (i) Physical; (ii) Psychological; (iii) Sociocultural; (iv) Spiritual; (v) Cognitive; (vi) Functional abilities; (vii) Developmental; (viii) Economic; (ix) Technology; and (x) Life-style. (3) Priority of data collection is determined by the client's immediate condition or needs, health status, and setting. (4) Pertinent data shall be collected using appropriate assessment techniques. (5) Data collection shall include a technology assessment. (6) The data collection process shall be comprehensive, systematic, and ongoing. (7) Relevant health status data, including changes, shall be documented in an authorized record which is accessible and in a retrievable form. B. Analysis and Nursing Diagnosis. (1) The RN shall analyze the assessment data in determining nursing diagnoses. (2) Measurement Criteria. (a) The RN shall analyze the data, consider the options, including technology, and make a determination as to whether the selected options are appropriate for the needs of the client. (b) Nursing diagnoses shall be: (i) Derived in a complete, systematic, and ongoing manner from the assessment data; (ii) Validated with the client, family, significant others, and other members of the health care team, when possible; and (iii) Documented in a manner that facilitates the determination of expected outcomes and plan of care. (c) Nursing diagnoses shall identify the nature and extent of the client's health status, capabilities, and limitations. C. Outcome Identification. (1) The RN shall identify expected outcomes individualized to the client. (2) Measurement Criteria. (a) Outcomes shall be: (i) Derived in a comprehensive, systematic, and ongoing manner from the diagnoses; (ii) Directed toward management of the client's health problems; (iii) Formulated with the client, family, significant other, or other members of the health care team, when possible and appropriate; (iv) Culturally appropriate and realistic in relation to the client's present and potential capabilities; (v) Attainable in relation to the resources available to the client; (vi) Documented as measurable goals with time estimates for attainment as appropriate; and (vii) Documented in an authorized record which is accessible and in a retrievable form. (b) Outcomes provide direction for continuity of care. D. Planning. (1) The RN shall develop a plan of care that prescribes interventions to attain expected outcomes. (2) Measurement Criteria. (a) The plan shall be: (i) Individualized in a comprehensive, systematic and ongoing manner; (ii) Developed utilizing available data; (iii) Prioritized to meet the client's condition or needs; (iv) Developed, coordinated, and communicated with the client, family, significant other, and other members of the health care team as appropriate; (v) Congruent with the client's therapeutic regime; and (vi) Documented. (b) The plan shall: (i) Reflect current nursing practice; (ii) Provide for continuity of care; and (iii) Include identification, coordination, and utilization of available resources. E. Implementation. (1) The RN shall implement the interventions identified in the plan of care. (2) Measurement Criteria. (a) Interventions shall be: (i) Implemented recognizing the rights of the client, the family, and significant others; (ii) Consistent with the established plan of care; (iii) Implemented in a competent, safe, and appropriate manner consistent with knowledge of scientific principles; and (iv) Documented. (b) Interventions may include, but are not limited to: (i) Patient teaching; (ii) Counseling; (iii) Implementing clinical practice guidelines, protocols, and pathways; and (iv) Independent nursing functions. (c) Selected interventions may be assigned and delegated to other personnel participating in delivering care. (d) When assignment or delegation occurs, supervision is provided. (e) A safe and therapeutic environment is provided for the delivery of nursing care. (f) Relevant information which may be needed to carry out the nursing plan is provided to the client, family, significant others, and other members of the health care team without violating the client's confidentiality. F. Evaluation. (1) The RN shall evaluate the client's progress toward attainment of outcomes. (2) Measurement Criteria. (a) Evaluation shall be systematic, ongoing, and criterion-based. (b) The client, family, significant other, and other members of the health care team shall be involved in the evaluation process, when appropriate. (c) Ongoing assessment data shall be used to evaluate the process of care and to revise the nursing diagnosis, outcomes, and the plan of care. (d) Revisions of diagnoses, outcomes, and the plan of care shall be documented. (e) The effectiveness of interventions shall be evaluated in relation to outcomes. (f) The responses to interventions shall be documented and communicated to the client and other members of the health care team. (g) The RN charged with the documentation of the client's discharge shall make the final nursing evaluation. G. Documentation. The RN shall maintain medical records in accordance with Health-General Article, Title 4, Subtitle 4, Annotated Code of Maryland. #### Regulation .03 Standards of Professional Performance. *COMAR 10.27.09.03* A. Quality of Care. (1) The RN systematically shall evaluate the quality and effectiveness of nursing practice in the aggregate. (2) Measurement Criteria. The RN shall: (a) Participate in activities to evaluate quality of care including, but not limited to, monitoring the structure, process, and outcome of nursing practice, with consideration for access and cost; (b) Use quality monitoring data to identify opportunities for improving care; and (c) Participate in activities related to implementing changes designed to improve care. B. Performance Appraisal. (1) The RN shall be accountable for evaluating the RN's own nursing practice on a regular basis in relation to professional practice standards and relevant statutes and regulations. (2) Measurement Criteria. (a) The RN shall: (i) Participate in peer review as appropriate; and (ii) Seek guidance, support, education, and supervision as necessary. (b) The RN shall demonstrate knowledge of and shall comply with: (i) Relevant professional practice standards; (ii) Statutes and regulations governing nursing; and (iii) The policies and procedures of the practice setting. C. Education. (1) The RN shall acquire and maintain current knowledge and competency in nursing practice. (2) Measurement Criteria. The RN shall: (a) Participate in educational opportunities and experiences to maintain professional competence; and (b) Obtain knowledge and skills appropriate to the practice setting. D. Collegiality. (1) The RN shall contribute to the professional development of peers, colleagues, and others. (2) Measurement Criteria. (a) The RN shall share knowledge and skills with peers, colleagues, and others. (b) The RN shall contribute to a supportive and healthy work environment. E. Ethics. (1) The RN's decisions and actions shall reflect ethical principles. (2) Measurement Criteria. The RN shall: (a) Comply with the Code of Ethics in COMAR 10.27.19; (b) Maintain client confidentiality within legal and regulatory standards; (c) Act as a client advocate and assist clients to advocate for themselves; (d) Deliver care in a nonjudgmental and nondiscriminatory manner that is sensitive to client diversity; (e) Deliver care in a manner that preserves client autonomy, dignity, and rights; and (f) Seek available resources to help formulate ethical decisions. F. Collaboration. (1) The RN shall collaborate with the client, family, significant others, and other health care providers in providing care. (2) Measurement Criteria. The RN shall: (a) Collaborate with the client, family, significant others, and other health care providers in the formulation of overall goals, the plan of care, and decisions related to care and the delivery of services; and (b) Consult with health care providers for client care. G. Research. (1) The RN shall participate in research activities appropriate to the licensee's position, education, and practice environment. (2) Measurement Criteria. The RN shall: (a) Support the client's rights related to research; (b) Participate in data collection; (c) Participate in identification of clinical problems suitable for nursing research; and (d) Utilize established facility-approved research protocols. H. Resource Utilization. (1) The RN shall consider factors related to safety, effectiveness, and cost in planning and delivering client care. (2) Measurement Criteria. The RN: (a) Shall assist the client, family, and significant others in identifying services and options available to address health-related needs; (b) Shall evaluate factors related to safety, effectiveness, and cost when performing, assigning, delegating, and supervising nursing care, and teaching the client, family, and significant others; and (c) As a case manager, may identify and facilitate options and services for meeting individual health needs by enhancing quality, cost-effective clinical outcomes while decreasing fragmentation and duplication of care. I. Assignment, Delegation, and Supervision. (1) The RN may assign nursing acts or delegate nursing tasks to individuals who are competent to perform those acts or tasks, when the assignment or delegation does not jeopardize the client's welfare. (2) Measurement Criteria. (a) When delegating a nursing task to an unlicensed person, the RN shall assess the client and determine that the delegation is consistent with COMAR 10.27.11. (b) When delegating a nursing task to an unlicensed person, the registered nurse shall: (i) Instruct; (ii) Direct; (iii) Regularly evaluate the performance of nursing tasks by the unlicensed person; (iv) Rectify a situation in which the unlicensed person under the licensee's supervision is performing nursing tasks incorrectly; and (v) Prohibit the continued performance of an unlicensed person who is performing the delegated nursing task or tasks incompetently. (c) When the RN is assigning a nursing act to another licensed nurse, the RN shall: (i) Verify that the nursing act is within the licensed nurse's legal scope of practice; (ii) Verify that the licensed nurse has the knowledge, skills and clinical competency to perform the assigned act; (iii) Verify that the assigned act is consistent with the facility's policies and procedures; (iv) Regularly evaluate the licensed nurse who is performing the assigned nursing act; (v) Rectify a situation in which the licensed nurse assigned to perform the nursing act has performed the nursing act incorrectly; and (vi) Prohibit the continued performance of the assigned nursing act by a licensed nurse who is performing the assigned nursing act or acts incompetently. J. Refusal. (1) The RN has the right and the responsibility to refuse to perform, assign, or delegate nursing acts. (2) Measurement Criteria. (a) The RN has the right and responsibility to refuse to perform a nursing act which is beyond the parameters of the nurse's education, capabilities, and clinical competency. (b) The RN shall obtain appropriate education, training, and supervision as required to perform nursing functions which are beyond the parameters of the nurse's education and clinical competence. (c) The RN has the right to refuse to accept responsibility and accountability for supervising, monitoring, instructing, or evaluating an unlicensed person performing a nursing task that has not been delegated by that nurse. #### Regulation .04 Specialty Practice. *COMAR 10.27.09.04* A. A registered nurse functioning in a specialty practice shall have additional education, training, and experience. Specialty practice does not include advanced practice nursing. B. Definitions. (1) In this regulation, the following terms have the meanings indicated. (2) Terms Defined. (a) “Critically ill client” means a client who: (i) Has developed or is at high risk for developing life threatening problems; (ii) Requires constant intensive multidisciplinary assessment and intervention to restore stability and prevent complications; and (iii) Needs restoration or maintenance of physiologic stability. (b) “Interfacility specialty care transport” means the movement of a critically ill client by transport vehicle when the client’s level of care requires the care of a registered nurse during transport. (c) On-Line Medical Direction. (i) “On-line medical direction” means oversight and orders by licensed physicians at base stations to EMS providers or members of the transport team providing patient care at an Advanced Life Support (ALS) or Basic Life Support (BLS) level. (ii) “On-line medical direction” includes medical orders and oversight by a licensed practitioner at a specialty care unit at a hospital to a registered nurse during a specialty care transport, provided the licensed practitioner is permitted by the facility to provide these services and the services are within the scope of the individual’s license. (d) Licensed Practitioner. (i) “Licensed practitioner” means a dentist, physician, nurse practitioner, nurse anesthetist, or nurse midwife or any other individual permitted by law and the facility to provide care and services within the scope of the individual’s license. (ii) “Licensed practitioner” does not include a student in a graduate education program whose practice requires supervision and whose orders must be countersigned. (e) “Specialty care transport” means transport for all ages of critically ill clients in accordance with the definitions under COMAR 30.09.01.02. C. Practice Specialty Care Transport. (1) Education, Training, and Experience Requirements. Except for the provisions under §C(2) and (4) of this regulation, a registered nurse who provides interfacility specialty care transport shall meet the education, training, and experience requirements for staffing an interfacility specialty care transport mission in accordance with COMAR 30.09.14.02G(1)—(3). (2) When a specialty care transport ambulance is not available within a clinically reasonable time, a registered nurse who has not completed a program of study in accordance with COMAR 30.09.14.02G(1)—(3) for the transport of patients by ambulance can provide interfacility specialty care, if: (a) The registered nurse has education, training, and experience in the critical care area required by the mission as determined by the referring physician; (b) The registered nurse is accompanied by an individual who is currently licensed as a Maryland ALS provider, in accordance with COMAR 30.02.02, to support the registered nurse with the transport; and (c) On-line medical direction is available to the registered nurse. (3) A registered nurse providing specialty care transport who does not have national certification for working with the client population to be transported shall have at least: (a) 2 years of clinical nursing experience in critical or specialty care within the last 5 years; (b) Age appropriate advanced life support training; and (c) Nursing expertise in the specialty care area required by the client’s age and diagnosis. (4) This regulation does not apply to, restrict, or limit: (a) Other health care practitioners who are authorized to perform these duties under their respective laws; or (b) A registered nurse providing care to a critically ill patient during a declared natural disaster or emergency. (5) A registered nurse is prohibited from accepting a transport assignment that exceeds the nurse’s knowledge and expertise.