Ambulatory Concern For Safe Staffing Form (ID #1049)Please enable JavaScript in your browser to complete this form. - Step 1 of 2IMPORTANT: Please do not include patient identifying information. To (Supervisor): *Unit/Department *Date *DateTimeI have notified you that the staffing provided is not adequate to meet the needs of the patients in this clinic at this time. Proper staffing has not been provided. Therefore, I am informing you that I am concerned in regards to any errors or incidents that take place as a result of the staffing level on this unit. Number of nurses indicated per grid/staffing tool:Number of nurses assigned:Was a request made to the ambulatory resource pool for coverage?If yes, what was response to request?Starting call volume:Starting MyChart volume:Starting medication refill volume:Clinic access for the day:How many providers were you assigned to cover?Estimated number of patients you were responsible for today?Familiarity with patient population 1=most familiar 5=least familiarPatient acuity: 1=low 5=highAnticipated non-clinic responsibilities for Nurse schedule:Did your site utilize a daily pulse check?Were options provided for extra support?Please provide any additional comments.NextAs a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our assignment is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patient. As a result, the facility is responsible for any adverse effects on patient care. NOTIFICATION YOU HAVE GIVEN (You must notify charge nurse and manager/ANC at the time of need or concern) FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING OR TECHNICAL CARE 1. Please indicate the reason(s) for use of this form: Insufficient Staff ScheduledUnexpected Call OutUnexpectedly High Acuity2. Specific staff deficiency (check all that apply)Inappropriate number of nursing staff (RN, LPN, LNA)Inappropriate number of technical staffInappropriate number of ancillary staff (CPSA, MHT…)No unit secretaryManagement's Response:Signature (type your full name)DatePreviousSubmit
