patient care essentials rounding care plan
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ESSENTIAL ASSESSMENTS PATIENT CARE ESSENTIALS ROUNDING CARE PLAN Personal needs Position Patient environment Discomfort or pain Devices Documentation Toilet requirements Change of position requirements Items in reach and environment safe Any form of discomfort, pain, ache All clinical devices related to patient care Document contemporaneously Patient care essentials to be assessed every hour. Initial in space that patient has been visualised and care essentials considered. If patient absent, mark ‘A’ in the assessment column. Date:_ __/___/___ 00_ 01_ 02_ 03_ 04_ 05_ 06_ 07 _ 08 _ 09_ 10_ 11_ 12_ 13_ 14_ 15_ 16_ 17_ 18_ 19_ 20_ 21_ 22_ 23_ I have assessed all the Ps & Ds The following required care was attended (initial only the care attended, otherwise leave blank) Personal needs Position Patient environment Discomfort or pain Devices (RN/EN) Documentation Is there anything I can do for you? (patient/carer) HAI2DET3: Hand Hygiene, Acknowledge, Introduce/Identify, Duration, Explanation, Thank you/Tidy up/Time Nursing Clinical Handover – Nurse initial that patient/carer was involved in handover. If patient unable to be involved put ’U’ and initial and document reason in Medical Records. Time Patient/Carer Printed name, initial & designation Printed name, initial & designation involvement (Nurse finishing shift) (Nurse on shift) PATIENT ID Bedside Clinical Handover will occur at least once per day and will incorporate: formal identification of patient, ISBAR communication, and involve the Patient and Carer. The Key Principles for Safe and Effective Handover are outlined in the NSW Health PD 2009_060:PCP 2 Last Updated: 28th August 2013 Bedside Clinical Handover will occur at least once per day and will incorporate: formal identification of patient, ISBAR communication, and involve the Patient and Carer. The Key Principles for Safe and Effective Handover are outlined in the NSW Health PD 2009_060:PCP 2 Last Updated: 28th August 2013
