Brigham and Women's Hospital Nursing Department: Report of Staff Concern

Name

Report Completed (Date)

Report Completed (Time)

:

Unit

Shift

Please check the category of concern that applies:

Other Category of Concern

Staffing Category of Concern

If your concern is related to staffing, please choose:

Brief Statement of Concern

RN

Regular	Per Diem	Float Pool/Other	Needed Staff to Provide Patient Care	Core Staffing as Set by Administration

LPN

Regular	Per Diem	Float Pool/Other	Needed Staff to Provide Patient Care	Core Staffing as Set by Administration

Ancillary

Regular	Per Diem	Float Pool/Other	Needed Staff to Provide Patient Care	Core Staffing as Set by Administration

Unit Coordinator

Regular	Per Diem	Float Pool/Other	Needed Staff to Provide Patient Care	Core Staffing as Set by Administration

Patient census at time of concern:

Unit capacity:

Acuity

amt. of nursing care required

Nurse Director / Supervisor Notified

Please add names of those notified, the times notified, and the responses here.

Email*

Please Note: a copy of this form will be emailed to this address for your records (you may not want to use your work email).

Comments

This field is for validation purposes and should be left unchanged.