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Workplace Situation Reports
Community Health Work Situation Report 2022
"
*
" indicates required fields
Section 1: General Information
Name(s) of Employee(s):
Are you an:
RN
LPN
Employer:
Main Office/Team/Area/Program:
Date of Occurrence:
MM slash DD slash YYYY
Time:
Hours
:
Minutes
AM
PM
AM/PM
Hours Worked:
On Call Hours:
# Regular Staff:
RN
LPN
PCA
Clerical Support
# Actual Regular Staff:
RN
LPN
PCA
Clerical Support
Staff Shortage Due to:
Sick Call
Vacancies
Emergency Leave
Vacation
Nurse Overtime:
Yes
No
How Many Staff:
Total Hours:
Did This Cause You to Miss Your:
Meal Period:
Yes
No
Rest Period/Break:
Yes
No
Name of supervisor reported to:
Section 2: Details of Occurrence
Provide a concise summary of the occurrence and how it impacted client care:
Was the safety of the client or the nursing professional compromised?
Yes
No
How?
Workload not completed:
Is this an isolated incident?
Yes
No
Ongoing problem?
Yes
No
Section 3: Client Care and Other Ongoing Factors to the Occurrence
Please check off the factor(s) you believe contributes to the workload issue and provide details
# Clients Assigned at Time of Occurrence:
# Clients Assigned at Time of Occurrence:
# Clients Assigned at Time of Occurrence:
# Family Members:
# Family Members:
# Family Members:
# Of Discharges from Program:
# Of Discharges from Program:
# Of Discharges from Program:
# Of Transfers from Service:
# Of Transfers from Service:
# Of Transfers from Service:
# Of New Clients to be Assessed (Ongoing Referrals)
# Of New Clients to be Assessed:
# Of New Clients to be Assessed
Presentation Cancelled
Presentation Cancelled
Change in Client Acuity:
Change in Client Acuity:
Change in Client Acuity:
Lack of/Malfunctioning Equipment
Lack of/Malfunctioning Equipment:
Lack of/Malfunctioning Equipment
Non-Nursing Duties
Non-Nursing Duties:
Non-Nursing Duties
Safety in Jeopardy?
Safety in Jeopardy?
Safety in Jeopardy?
Standards Not Met
Standards Not Met
Travel/Distance
Travel/Distance
Weather/Conditions
Weather/Conditions
Unanticipated Assignment/Uncontrolled Variables
Unanticipated Assignment/Uncontrolled Variables:
Unanticipated Assignment/Uncontrolled Variables:
Other:
Other:
Other:
Section 4: Workload
At the time of the occurrence, the planned workload was:
Documentation/Administration (i.e. Phone, paperwork, supplies)
Planned
Actual
Planned Time
Actual Time
Home visits/School visits/Clinics/Telephone Calls/Hospital/etc.
Planned
Actual
Planned Time
Actual Time
In-service Education/Presentations
Planned
Actual
Planned Time
Actual Time
Number of Clients Assessed
Planned
Actual
Planned Time
Actual Time
Public Meetings/Team Meetings/Office Work etc
Planned
Actual
Planned Time
Actual Time
Travel (number of trips)
Planned
Actual
Planned Time
Actual Time
Other (i.e. giving a presentation, etc.)
Planned
Actual
Planned Time
Actual Time
If staff made available, please identify the number of staff provided, their category:
Category
Amount of Time Staff Available
Orientation to Site Required
State Orientation Time
Orientation
Yes
No
State Orientation Time
Category
Amount of Time Staff Available
Orientation to Site Required
Yes
No
State Orientation Time
Category
Amount of Time Staff Available
Orientation to Site Required
Yes
No
State Orientation Time
Section 5: Recommendations
Please check-off one or all of the areas below you believe should be addressed in order to prevent similar occurrence:
Recommendations
Caseload Review of client/family needs
In-service
Orientation
RN Staffing
LPN Staffing
Clerical Support
Part-time pool
Perform Workload Measurement audit
Professional standards
Review policies and procedures
Review: RN-Client Ratio
Review: LPN-Client Ratio
Equipment:
Equipment:
Recommendations - other
Other:
Other:
Section 6: Employee Signatures
I/We request these concerns be forwarded to the Professional Practice Committee
Signature:
Date:
MM slash DD slash YYYY
Signature:
Date:
MM slash DD slash YYYY
Signature:
Date:
MM slash DD slash YYYY
Signature:
Date:
MM slash DD slash YYYY
Date Submitted:
MM slash DD slash YYYY
Time:
Hours
:
Minutes
AM
PM
AM/PM
Section 7: Management Comments
Please provide any information in response to this report, including any actions taken to remedy the situation where applicable.
Management Signature:
Date
MM slash DD slash YYYY
Section 8: Recommendations of Professional Practice Committee
The Professional Practice Committee recommends the following in order to prevent similar situations:
Is this issue resolved?
Yes
No
Manager Email
*
NBNU Local President Email
*
Member Email
*
Dated:
MM slash DD slash YYYY
