¨ Make night rounds sheet with suicide levels and risk
factors, NPO
¨ Rounds for days / pm
¨ Census board; physicians and ward clerks census
sheet
¨ Assignment sheet
¨ Acuity
¨ Chart till 0000 hours in all charts
¨
Chart audits: dates and times, all
problems correctly stated and addressed… and signed including continuation, TPR,
admission and other [e.g. 5250] paperwork complete, all papers in place and
dated… Blue slips for deficiencies
¨ Change date on patient information board
¨
Patients are in correct rooms and beds
and match patient information board; look for unusual / unsafe items in all
rooms – shoes with laces, too much supplies etc… LOOK everywhere
¨
Patients on S/P II are checked Q 30
min; be especially aware of patients with med/sleep concerns e.g. sleep apnea
and patients with C-PAP machines
¨ Unit safety check including restraint room and bed;
restraint key works?
¨ Are patient telephones off?
¨ Check patio for property / unsafe items; check /
lock SALLI port door
ASSIGNMENTS AND DUTIES
¨ Check your assignments = your patients and tasks [letters A – P.] Responsibilities include:
Check with you team nurse to review special concerns for the shift and any special do’s and don’ts
Review your patient's charts for the problems, behaviors, goals and
interventions in the treatment plan.
[The treatment plan is one of the most important documents in the chart.
Thoroughly familiarize yourself with the structure of the plans and the
planning process.] Also read progress notes - doctor/social worker/nursing.
All shifts are required to chart on at least one problem; however plan to chart
to all problems for which information becomes available, especially the main
psychiatric problems such as danger to self, depression, psychosis – these are
the problems that are the focus of treatment and show medical necessity
Usually there will not be any significant
opportunity to observe patients behaviors or have a 1:1 with patients. However,
if the patient remains awake you may observe significant behaviors that should
be charted; otherwise it may at times be appropriate to say ‘unable to assess
because patient appeared to sleep.’ Chart to sleep issues and any
medical concerns that arise
¨ Sanitize
bathrooms, light switches, chairs, towel and arm rests, chairs, doorknobs
¨
Check TV room for order, cleanliness and if closets are locked.
Check / remove garbage; check / wipe tables; put away activity supplies. Staff
lounge; coffee for day shift
¨
Paper towel / soap dispensers: staff
lounge, property / utility / treatment rooms, handicapped shower room. Gloves:
fill when necessary
¨
Laundry: refill water in lint catch, remove lint; restock
client supply chart; stock linen cabinets and remove linen from counter tops if
space available; tidy and remove stray items including excess empty boxes.
Washing and drying clothes; label; attempt to identify unlabeled clothes.
Laundry soap – is there enough. Yellow, red, water-soluble bags. Take linen
bags upstairs; replace
¨ Complete assignments