CARE DOCUMENTATION FORM

DOCUMENTATION OF INABILITY TO COMPLETE CARE

Dept.

Date

Shift

Overtime worked (minutes/hours)

Were you staffed to ratios/matrix? Yes No

Did the lead nurse have to take a pt. assignment? Yes No

Were you staffed per GRASP criteria? Yes NO

Please check the boxes corresponding to the care you were not able to complete during the shift.

Please use the free text area to explain or elaborate*

**adequate observation of patients** Fill out AUP 

adequate resource of LVN

adequate resource of Float Nurses

delay in implementing new orders

timely administration of routine medications

timely administration of prn medications

charting

baths

turning q 2 hrs

ambulation as ordered

restraint protocol

supervision of pt. on commode/in bathroom

timely incontinent care

foley care

dressing changes

pulmonary toilet

oral care

trach care

dysphasia protocol

pt./family education

other (see free text area below)

Free Text Area:

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