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:_ __/___/___
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01_
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08
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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