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

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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).

Phone

Optional