NIGHT SHIFT MHW CHECK OFF SHEET – SV

¨      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

NIGHT ROUNDS. Q 30 min. Report anything unusual or unsafe to the CN immediately

¨      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