|
18.88 RCW Registered Nurses WAC
308-120-700 Standard of Nursing Conduct or Practice
Staffing
count on date of objection:
Census:_____
Acuity (check one): High_____ Average_____ Unit Capacity_____ Admits__________
Transfers________ Discharges_______
Staffing
numbers: RN _____ LPN _____ Aide_____ Clerk_____ Agency nurse_____ Float nurse
_____
I,
__________________________, a registered nurse employed at
(facility)_____________________
on (shift)
________________/ (unit) _____________________ hereby object to this assignment
made to me by (supervisor)_______________________ at (time) __________ on (date)
______ .
My
objections are based on the grounds that I was:
( ) Not
oriented to unit ( ) Not trained or experienced in areas assigned () Transferred
or admitted new patient(s) to unit without adequate staff ( ) Given an
assignment which posed a serious threat to my health and safety ( ) Not given
adequate staff for acuity
( ) Staffed
with excessive registry personnel
( ) Staffed
with unqualified registry personnel
( ) Staffed
with excessive number unlicensed personnel
( ) Short
staffed
( ) Not
provided with unit clerks
( ) Other
(Please specify)_________________________________________
In order to
avoid further jeopardizing patient care, I will accept the assignment as
instructed, despite my objections.
Brief
statement of problem: (i.e. type of patient, # IV meds, special procedures)
_____________________________________________________
________________________________________________________________
________________________________________________________________
Signature of
nurse initiating form:
_______________________________________________________________
Position (
)Charge nurse ( ) Primary nurse ( ) Team leader ( ) Team member
Action taken
by nurse: Notified nursing supervisor (Time)_________
(Name)________________________________________________________
Signature of
Vice Chairperson _____________________________________
After
completing this form and making copies, take time after you're off duty, to sit
down and write an account of your shift and keep it in your personal file.
Make
4 copies of this form after completion; one each for:
1.
The nursing supervisor
2.
The UFCW office
3.
Unit Vice chairperson
4.Your
personal file
Protect
your license! Print
and use this form
|
