Staffing Assignment Report
18.79 RCW Registered Nurse WAC 246-839-700 Standard of Nursing Conduct or Practice "The nurse shall be responsible and accountable for the quality of nursing care given to clients. This responsibility cannot be avoided by accepting the orders or directions of another person." Staffing count on date of objection:
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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 |