Nursing Process

Toolkit Materials

• Nursing Scorecard

  A nursing chart review tool to be used in performance improvement. This tool can be used as a guide to ensuring that proper documentation is in place related to select nursing processes addressing patient safety.

• Nursing Responsibility Risk Assessment

  A risk assessment tool to evaluate process which require specific training and supervision by a registered nurse.

• Discharge Process Risk Assessment

  A risk assessment tool to evaluate the current discharge process in place as it compares to best practice and regulations.

• Unit-Based Nursing Scorecard

  This tool is designed to serve as the dashboard of aggregated data for the Nursing Scorecard. This tool allows data entry of overall unit performance with the elements in the Nursing scorecard chart review tool.

• Nurse Burnout Podcast

  Nurse Burnout compromises patient care and the health of an employee. Burnout is a type of human factor causation that can be associated with many adverse events such as higher mortality rates and medical errors. Listen to our podcast to learn more about behaviors that occur with burnout and simple things leaders can do to prevent it from occurring.

• Readiness Rounds: 9 Approaches to Patient Satisfaction Real Time

  Tools and tactics to improve patient satisfaction in your organization.

• University of Maryland Baltimore Washington Medical Center: Purposeful Hourly Rounding

  Provides a step-by-step approach to implementing purposeful hourly rounding.

• Sample Bedside Shift Report Letter

  Provides verbiage that can be given to patients upon their admission to your healthcare organization explaining the bedside shift report process.

• Bedside Shift Report Guidelines and Key Words

  Guidelines for the bedside shift report process can increase patient safety and improve quality of care.

• Bedside Shift Report Tips

  Tips to successfully hardwire bedside shift report in your organization.

• Bedside Shift Report: Framework for Communication

  A framework for communication between members of the healthcare team during bedside shift report.

• Article: Bedside Shift Report Improves Patient Safety and Nurse Accountability

  This article provides evidence-based practice regarding how bedside shift report improves patient safety.

• SBAR Communication Tool

  Guidelines for how to communicate patient information to the physician in a succinct and effective format.

• Pain Assessment and Documentation Tool

  A sample tool to record and facilitate ongoing evaluation of a patient’s pain and documentation of pain management.

• Patient Ticket to Ride

  A template for your organization that provides immediate critical patient safety information to accompany patients leaving the unit.

• Handoffs in the Postoperative Anesthesia Care Unit: Use of a Checklist for Transfer of Care

  Provides information regarding the need to have a standardized process for handoffs in the PACU patient care area.

• Preceptor Delegation Tool

  A step-by-step checklist for the preceptor to delegate tasks to the preceptee.