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What issues are documented during a safety check and how are they documented?
- Whereabouts of patients, safety of patients, amount of suicidal patients are written on a board and wand to wall in each room.
- Patient location & behavior on a 24 hour rounding sheet
- Per visit note, per question asked and answer received.
- Patient activity is documented on the patient checklist
- Each patient has a hand written check sheet which lists patient’s location, behavior, and presence or absence of visible contraband is documented.
- Location and mood of patient
- Location of patient, who is with them, what are they doing at time
- Location/activity
- Patient location and activity. This process is still on paper. Staff carry a clipboard and document concurrently.
- Activity at present is documented by computer clicks in flow columns on computer and on hard copy sheets that technicians carry.
- Outlets, clutter, contraband, fall hazards, sharps, cords & pills
- Location of patient and if they are awake or asleep.
- What the person is doing (sitting, standing, showering, etc) and their location (room, day room, bathroom etc).
- Location of patient and activity of patient on a paper form with boxes for every 15 minutes - use codes in the boxes to indicate location and activity
- Activities of the patient including respiration when sleeping.
- Environment checks are done every hour
- Client safety, on a check sheet
- Environmental issues through our Peminic reporting system
- Restraint safety, fall risk, suicide precautions all documented on flow sheets in EMR
- Where patient is is documented on a check off list
- Behaviors & whereabouts on a flow sheet
- Change in patient condition documented in medical record. Milieu or physical issues on the rounds sheet itself / repairs are documented on work orders
- Location of patient, if they are sleeping, in restraints, lock door checks, 1:1, staff signature, times, date shift.
- Location of patient and behavior
- Brief behavior codes on a check sheet and for 15/30/60 min checks. Broset Scale each shift all points are filled out for each patient
- Patient location and observed activity
- Check mark on the Q 15 check form with the code for where\was the client:
- Room check
- Client environment check
- Location of patient and sleeping if they are sleeping
- A check off on the electronic record indication 15 minute rounds conducted for safety and a paper 15 minute check off which notes location of patient only
- Rooms are checked, locks are checked, looks for hazards (water on floor, obstructed exits, etc.)
- Patient location & activity; room/contraband search
- Location of pt
- Pt location, activity, mood, behavior
- Pt. rooms, door checks, bathroom and fall safety
- Location and patient activity
- Location of the patient.
- The patient’s location and activity/ behavior, with the level of detail depending on the acuity
- Where pts are located and awake or asleep--signed off on flow sheet
- Unit safety checks--search rooms, signed off
- That doors are securely locked no one in hallways that should not be there.
- Location of the patient, that the "sharps" have been accounted for, and other environmental issues have been checked - there are specific areas to initial on a spread sheet.
- It is a check sheet identifying location for the 30 min checks. If more frequent checks like q15" are needed the form has you indicate specific behaviors using a key guide
- There really is no place on the checks board to document anything
- A check mark on paper
- Patient chart and PSN (incident report) any item that should have been secured. We have found lighters, bullets, string, pills etc
- Location of patient, activity that patient may be engaged in (attending CBT group, etc and if on nights and/or sleeping that respirations were noted at time of check
- Alert/asleep, where they are, unsafe items, unsafe environment (loose screws, damage to furniture, etc.)
- We primarily document location of patient; on night shift we also document whether asleep or awake
- Patient accounted for
- Patient location, physical appearance, behavior/mental condition, interventions. These are documented on a rounds sheet with check boxes.
- Ex; counting dinner ware, providing felt tip pen vs. ballpoints that have metal, item by item inventories, unannounced room checks.
- Location
- Location and behavior
- Whearabouts and activity of patient at the time environmental safety checks done daily
- Patient whereabouts are documented on a flow sheet to include location and if it is at night, then the sleep status is also included.
- It depends on what is occurring at the time of the safety check.
- Activity, Location, who with; Document on flow sheet
- Contraband, patient having a difficult time, discussed with other staff and document in the chart and in the Resource Nurse Binder: Location, mood, sx.
- Pre-printed form: Contraband, interactions, restraints, beds
- Checklist: Location of patient
- Where is the patient, what are they doing, what does their behavior indicated. Documented with initials.
- The patient's behavior and their location. This information is documented on an observation round form. Each patient has their own individual observation form.
- Are doors locked that are not in use? Scan empty rooms for sharp objects, that patient is alive, safe & breathing - documented with a checkbox method on clipboard
- Location of patient and, if there is a concern, patient behavior
- Where patient is and sometimes mood behavior
- Location, outstanding issues, need for prn med, effectiveness
- Patient safety checks/observations are only whether patient is awake or sleeping and breathing. Documentation is on a paper sheet that has staff signatures and all patients listed with a photo, room assignment and observation level. Fall risk is indicated on this form as well as elopement risk.
- Patient location
- General appearance, activity - in short narrative.
- Location (Day Rm, Group Rm, Bedrm), Behavior (Calm, Agitated) Actions (Talking, Sleeping) Check sheet w/ codes (DR, C, T) (Day Rm, Calm, Talking) Staff sign the sheet and initial each entry.
- Checked that patient was visualized, and if sleeping, respirations noted
- Awake or asleep is documented
- Time, location, demeanor, any escalation or interaction
- Pt whereabouts on a board with a key legend indicating areas of the unit and activity
- Head counts, any irregular activities, issues for specific clients
- Any reported near miss, or error, or unsafe environmental issue, practice, or process is documented and followed up with action plan by a combination of the unit/program leadership and the system quality/safety committee.
- Doors locked, glass or other breakable, sharps, pop cans, hangers, plastic bags, lighters, matches, home meds, damaged equipment, other
- Location of patient and awake or asleep
- Patient's location and whether they are awake or sleeping.
- Room deemed safe, si, hi with plan and/intent as applicable
- We have a "Special Alert Status Checks sheet" for patients on any kind of precaution with documentation lines and check boxes; the minimum expectation if not on special precautions is a Census and Wellness Form that allows for 15 minutes checks as well, but is usually used for 60 minutes checks.
- Whether the client is asleep, awake or on pass is indicated on the check sheet every 15. Any other significant behavior or event is documented in a progress note.
- Check marks and comments. Where they are, what they are doing, and behaviors needing notes.
- Where the patient is located, awake or asleep; we document that it was done & by whom
- Broken equipment, patient room doors closed, other environmental hazards
- The patient location and if asleep or awake is q 15. The patient room check is documented in the flow chart.
- Location, awake or asleep, and any out of ordinary emotional state
- If the patient is or is not suicidal (if patient is suicidal then they will be asked to come to dayroom for closer observation) and if they can agree to tell staff if they do become suicidal
- Where the patient is and activity level
- Time, location of patient on the unit (requires only a # related to a key), Behavior (requires only a letter, related to a key), staff signature.
- Check off for apin, potty, positioning, clutter on floor, lights, and safety hazards in room.
- Patient’s alive status on unit
- Documentation is by a check mark on a form and the location. The CNA's are primarily responsible for safety checks. If there is an issue, they report to the charge nurse.
- Safety check issues are divided on two separate categories: clinical vs. structural. Documented on a safety check list and communicated to maintenance or CE immediately. Clinical check of findings documented on the patient’s daily notes.
- Patient location and activity. Initials on rounding sheet
- 1. Location of patient, 2. Condition of patient 3. Conditions in the environment that may affect the safety of the patients
- Where the patient is, what they are doing - in the electronic record
- What the patient is doing and where the person is if patient is on q15 checks. Documented on a flow sheet. If person not on q15 minutes check is not documented.
- Patient’s location only. We tried documenting location, activity and behavior/mood, but staff felt it was too cumbersome
- Patient location, room environment checks... Documented on flow sheets
- Patient location
- Behavior/activity, e.g. sleeping, eating, etc.
- Are they awake, sleeping or off the unit.
- Sleep, location, what discipline they are with, patio, room, dayroom,
- Presence, location
- Respiration, location and time
- Location of patient
- It's documented if they are awake, asleep, calm, or agitated,
- We have a q15 check list for our NAs and MHAs and I document in my notes
- Our unit uses a safety check "matrix" that includes pt's name w/ small boxes indicating 1/2 hr time intervals. We use pre-set initials to indicate what pt is doing or where pt is at that time; i.e., LR (in living room), MD (w/ doctor), BR (in bathroom), etc.
- Location of patient; activity engaged in
- Behavior, location, time
- The key on the checks sheet reflects: on hall, off hall, awake in bed, sleeping and breathing
- Where a patient is at the time check
- For patient safety checks, patient exact location is documented. For environmental safety checks each pt room is observed for potential hazards, contraband and repair needs.
- We document them in the computer
- Location of patient - on unit, in group, appears to be sleeping
- We document where the person is and what they are doing
- Location/activity- time- staff initials on a check sheet with all the names of patient
- If a routine separate sheets on same board if on 15 min checks one-one also have a separate check sheet and one person is responsible for maintaining this assigned board
- Multi-patient flow sheet by location only
- Using a numbered list, the check describes the placement of the patient or the behavior
- It depends on the safety check. The routine safety checks documents where the patient is located. It is a visual check unless the patient in off the ward. During special observations and 1:1s, the patient’s location, mood, and activity is documented.
- Hourly and q 15 minutes - none; 1:1 - Pts. location, behavior, activity
- Each patient's location at the time of the rounds, each patient's behavior at the time of the rounds, each patient's risk issues / precautions.
- Patient's location, Patient' activity, Patient awake or asleep
- We started just documenting on a sheet what was found and removed from the room on room checks. This is to assist in tracking and help with new staff orientation.
- Found items and where, plastic bags, glass items, cords, razors, tin cans, pills, exits locked, windows intact, cigarettes matches lighters
- Any hardware deficiencies, hazardous items etc
- Status and location well documented
- Physical whereabouts of the patient
- Location for all; during hours of sleep we note if they have eyes closed or eyes open - we monitor sleep times; if the patient has a 1:1 it's noted
- Flow sheet; can't say specifically what is checked as I do not work on the inpatient unit
- Based on description above #1 location of patient, and at night, whether or not the patient is sleeping; #2 presence and description of any contraband found; #3 doors that are to be locked are locked, hardware working properly, pagers and alarms working, intercom system working...etc. If any repairs are indicated, a work order is completed.
- Do a personal and belongings search on admission and after a TLOA. Document electronically on a flow sheet. Specify items locked or removed from patient room.
- What person is doing, level of alertness, surrounding, door security, look for cords, items that could be used for self harm, sharp edges, behavior of person- depends if routine or if related to a concern- During sleeping hours make person is breathing, look for position change
- For the 15 min checks on each pt we have one sheet with every pt's name on it. Codes are used to indicate where the pt was and what their behavior was at the time. For the checks done once a shift a different check sheet is used that includes whether or not doors are locked, wet towels removed from bathrooms, staff wearing name pins etc
- Rounds sheet with check boxes. If something is amiss, it is immediately rectified by the person responsible for rounds at the time.
- Rounds were competed by wand, computer generated
- Unusual behavior or problems are charted on computer
- In what activity was the person engaged? (Group, sleep, etc)
- Patient behavior environment patient location
- Environment, pt location, verbalization of self harm, level of precautions and for what reason pt is on precautions. Documentation is only performed on the hour.
- Patient location
- Patient clinical status: depressed, anxious, situationaly appropriate, etc.
- Charting on flow sheet. Document additional information under current behavior
- Door locked, rooms locked, stairwells locked etc.
- In a book: patient location, patient activity
- Patient location, activity, behaviors
- Patient whereabouts, pt. complaint. Documented on the rounding sheet and shift summary report
- We document where the patient is located when we do the safety check. We document if someone signs out a sharp item, which is an item that could be used as a weapon to harm themselves or others examples would be a portable DVD player, a razor which needs to be used in staff supervision and turned back in immediately. Cds music or DVD’s, portable CD players, notebooks with wire binders etc.
- What the patient is doing (behavior) is documented on a Checks board document
- Any sharps or contraband, any environmental concerns, dangerous items, unauthorized materials such as notes from other patient's
- Where a patient is.....and there is a flow sheet that is used
- Just a check showing that a 15 minute check was completed. The check is placed by the name of the patient.
- Patient whereabouts
- Where the pt is and what the pt is doing
- Q 15 min-q 2 hr
- Specifically list rooms; and what we are looking for: doors locked, items secured, no shoelaces, belts, etc. PS I would be happy to share our unit specific form
- Their location
- Location, activity: Number codes for location, letter codes for activity
- Safety checks are initials by staff performing safety checks as well as if a problem as identified or a concern.
- Location and activity of patient
- For 30 min checks we have a one page grid with times across the top and patients names down the side. We document their location on each safety check. For 15 min. checks there is an individual form for each patient; staff document location and initial each time.
- All potential weapons, trays, dishes, cups, mugs etc as well pt status i.e. awake, sleeping, etc
- Location and activity of patient. Documented on 8 hour "rounds board" divided into 15 minute segments. Person doing rounds must initial each segment.
- Behavior and location on a rounds form for each patient. A legend and numbers are used for the location and behavior respectively.
- What patient is doing
- Where the patient is. What activity they are performing
- Where the patient is and what he is doing
- Safety checks: tattoos, injuries, contraband; Rounding: patient sedation level, location, environmental concerns, noted on special board/ documentation saved.
- Location of the patient, activity of the patient and behavior of the patient (LAB)
- Check boxes denote if pt has questions, concerns, or needs to be reminded to participate in groups.
- They are documented on our Epic System and it describes patient's activities 24/7
- Exactly what you did and the result of your check
- Location, activity, and if notable level of anxiety
- Location and behavior, on rounds sheet.
- Location is documented on rounding form. Safety issues are reported to charge RN and charted in pt record.
- Location of the patient, what activity the patient is involved in, who the patient is with,
- Any contraband items found or unusual behaviors observed
- Where they are, and if awake or asleep
- Type of monitoring (medical, SI, HI, psychosis, falls etc), personal safety & environmental checks
- Presence medical equipment or other potentially "unsafe" items, e.g. call light cord; restraint gurney is checked for readiness; doors locked; documented on mental health tech's flow sheet
- Location, activity - checks
- Where the patient is and what they are doing. If exit door are locked. Bathrooms do not have anything in them. Dryer is clean.
- Where and, problems, on a checklist
- Rounds board for location, any contraband found is documented in medical record, policies followed for removal of contraband and/or safety issues (i.e. broken chair) broken items reported to facilities
- Location, mood and behavior are documented on a Flow Sheet.
- Usually where the patient is at the time and the activity they are engaged in - done through a simple check off sheet with staff initials.
- Check off and kept for 7 years. One place to document on the chart each shift
- Where the patient is and what they are doing is documented. There is a safety check sheet for each patient, with a key to designate location and behavior, and a small space to add comments.
- The patient's physical location is documented by using a code system i.e.: B=bathroom, D=dining room S=sleep
- Patients’ whereabouts
- The time, date, patient identifiers, location of the patient are kept on "rounds" sheets.
- They are documented on paper. We note the place and the activity
- Staff initials and signature, pt location
- Where the patient is and what the patient is doing. Documentation is done on individual flow sheets
- Patient location, risky behaviors, environmental safety
- Asleep/awake, location, initials of staff documenting
- No documentation other than to check off when a pt is accounted for
- Any opened doors that are supposed to be locked, objects that are found that are high risk for the environment (razors, laces, tourniquets, draw strings...) and patient location (IE off unit for PT, x-ray, RT...)
- Where client is at, what client is doing, and their behavior.
- What the patient is doing are they stable
- Paper sheet for individual pts, paper sheet for unit checks, documentation in the electronic record, verbal handoff during shift sign off
- Check off sheet with pt name and room number
- Patients whereabouts and a checklist is used for rounds
- Where patient is, what patient is doing, what was done about problems, patient's ability to follow directions/level of agitation, contraband found, MD contacted, etc.
- On the intensive care unit the patient's location & activity/behavior on individual flow sheets. On the step down unit just their location on 1 common flow sheet.
- Mood, behavior, cognition. Documented in CRIS.
- Safety checks between change of shifts has a formal checklist but issues are not documented just corrected i.e.: plastic bag in the room of pt discarded on proper receptacle (station), routine checks are documented on unit rounds board, more frequent 15 min checks documented on individual patients if ordered.
- Where the patient is and what they are doing in general
- What the patient is doing, if is responding to internal stimuli, behavior, if patient is watching TV is important to assess if really is concentrated in the TV program
- Document on grid with "key" letters designating where the pt is and what they are doing.
- We document when check done and initials of person completing the check. If contraband found, that would be documented in patient care notes.
- Individual safety checks are ordered and specify in the order what the staff member is to observe and document
- On paper the patient's physical location
- Location is documented on a paper version of an Excel spreadsheet
- Clothes with draw strings, ADL items left in room, etc., items are removed. No process for reporting formally the staff will leave notes depending on the breach of safety.
- Mood & behavior of each patient, on the individual's flow sheet for each shift
- 1) Typically we monitor, behavior, or medical/safety issues. 2) Special op's here are 15'checks, and 1:1, 15' checks...q 15 & 1:1 q 30'
- Nursing Attendants' flow sheet is document of status of each patient: Awake; asleep; w/ doctor; off unit.
- Where the person is
- Location, activity, pt's presentation/mood
- Activity, behavior, location
- Where the child is located, if sleeping or awake
- Flow / check sheet, where patient is, activity, environment
- Location on a sign off sheet
- This is a checklist done by our Psych aides
- Location and behavior
- Awake/asleep
- If person engaged in unsafe practices, tech would contact nurse for assessment/follow-up.
- For patients: all precautions ordered (fall, aggression, anxiety agitation, etc)
- For Rooms; what contraband was found or that nothing was found
- Location: abbreviation key
- Large unit...nursing assistants can’t always get around to all the patients
- We decided to take out behaviors from our checks document so we document location. The only behavior is sleep. We decided no matter where they are if they are sleeping that is important information. So Z is for sleeping. Otherwise it is location such as room, hallway, dayroom, dining room, and group.
- We have a board with each patient name, the safety or precaution status i.e. suicide precautions violence precautions, fall precautions, seizure precautions, the staff must see the patient and mark down on the board where they are what they are doing
- Patient status, what was checked and if any contraband or safety hazards found
- Patient's behaviors, activities, responses
- Any structural problems, contraband and removal, safety issues in general--check sheet is filled out and signed by staff member completing the check
- In the computer: Purpose-behavioral, Visual check-location
- Location of patient, awake or asleep
- Correction Officers keep a log on activity observed during that check
- Computer charting how often checks done, mood behavior and what activity involved. Complete assessment every a.m.
- Documented on check sheet. Patient location
- There is a log book for routine rounds and contraband rounds. If there is an issue with a particular resident it is documented in the resident progress note.
- Check sheet indicating that you saw the patient
- Location, activity and behavior of patients
- Sleep/awake, verbal/social, visitors, group, location
- Self harm, harm to others, via verbal or behavior cues, and environmental checks. Computer documentation
- Neck visible, activity such as in dayroom, sleeping in room, with visitors
- The status of the patient is documented. Whether they are in a particular area, awake, or asleep.
- Time, location, patient behavior, intervention. They are documented on a single form for continuity.
- What is found, consumers whereabouts and activities
- Location/activity
- Shower rounds, cafeteria rounds, where patients are located, documented via codes on the census rounds sheets.
- Where the pt is and their current behavioral state.
- Depends on purpose of check: pt location, activity, behavior, statements made, etc
- Checklist is used time, behavior, activity, use of seclusion/restraints, neoro/motor/vascular using a check sheet
- Each guest has a flow sheet that becomes a part of the chart. On this sheet, besides documenting the location, hours of sleep are also noted
- Patient whereabouts checked off on a sheet listing all patient names & room numbers. Alarmed doors checked 3 times per day & marked off on check off list.
- Patient location and activity are documented. An environmental safety check is also documented every 8 hours that identifies potential risks.
- Any potentially harmful objects found
- Where patient is, what is happening, what bx are being exhibited
- Any positive safety risks are documented on the change of shift report and in the patient's progress notes
- Location, behavior and who is doing the check
- Check box indicating behavior and location.
- Location and activity
- Questions asked danger to self or others? Voices? Voices directing harm? Agree to let us know if unsafe?
- Patient health, complete environmental safety, high risk area checks
- Documented on paper every 15 minutes use numbers to indicate where the patient is located and whether he/she is awake or sleeping
- Documented where and what the patient is doing. Use a paper document. Will soon have the option of using the computer but will continue on paper because the computer option is too cumbersome.
- Patient location/activity time, date, and staff initial. Documentation is on a flow sheet
- Patient location and what they are doing at that time
- Location & activity through a check list
- Contraband found in rooms during room checks
- Where the patient is --all documented on flow sheet
- Issues such as increased agitation, responding to internal stimuli, etc are documented in the nurse’s notes
- Location and, for the evening, asleep/awake is documented on paper with patient photo/ID label
- Our rounds sheet has a paragraph defining all areas that are looked at during environmental safety checks and the staff initial off when they have completed their assigned safety checks
- Patient's location documented on rounding form
- Pt location and behavior at time of location. They are documented on a flow sheet.
- Alertness, ideations, delusions.hallucinations, anxiety, depression, pain, appetite, fluid intake q shift when 1:1 q hr, v/s
- Awake, on phone, in shower, etc. a canned text of pt being awake or asleep and where they are
- EMR in note and passed on in report
- That the pt is safe, not harming self, attempting to hide, etc.
- Where the patient is located at the time
- They document that the unit is safe, report any environmental concerns or repairs needed. They check all bedrooms, common areas for contraband, hazards, etc.
- Patient safe and location
- Location of patient, anything atypical
- Just the fact that the patient was seen and where. It’s implied that they were safe. We document this in the computerized medical record
- If anything unsafe noted on patient, in room, or on unit in front of report book and communicated in report
- Location of patient and what they are doing at that time
- Patient’s location/activity by abbreviation code and there environment, safe scan by a 1 indicator
- Pt's location and behavior, on a checklist.
- Pt's location & behavior, on a checklist
- Doors locked, absence of sharp objects, furniture in good working order free of disrepair, no broken fixtures...Patient is awake, resting in bed, sleeping, in group or up
- Sleeping, awake, location. Check sheet for each patient’s w/specific abbreviations for each
- Discovery of contraband items documented via incident report
- Location, asleep/awake. Several RNs on the unit are sure to note respiratory status if patients are asleep. Our form has separate sections for depression, anxiety and pain but I have never seen anyone document re those issues on that rounding form.
- Code used to document of the location of the patient.
- 30 minute checks are only documented at night from 2300-0730. 30 minute checks on days and evenings are done but not charted unless the patient is on 10 minute checks in which case, these checks are always charted.
- Location of the patient
- Location
- On the standard 30 min check, location is the primary documentation. If on 15 min checks, location as well as brief description of behavior is noted.
- On paper. Patient's location, patient's behavior, and any unsafe objects present, like extra linen, etc.
- Several parameters are noted on a rounding flow sheet that is initialed by staff performing the rounding. They include location, group, room, lounge, sleeping, to name a few.
- Time, location, activity of patient, person doing the checks. Documented on a form signed by all staff conducting checks.
- Documented in EPIC
- If patient feels safe, if patient is suicidal, if patient is agitated, if patient has a problem with another patient or staff
- If we are evaluating the dangerousness of a particular individual, we perform a mental status assessment and work to build an alliance with the individual. We try to understand how he thinks--what he thinks. His psychotic logic. We closely observe his behaviors, including quality of eye contact, gesturing, staring etc. The observers must document what efforts they put forth to restore the individual to safety. These patients need cognitive interventions, to assist them in examining their assumptions. They need behavior therapy to create a supportive "Holding" environment where he feels safe and others feel safe. Use peer influences, build from his strengths and know his life goals.
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