PASNAP Documentation of Inadequate Staffing Situation - Lower Bucks
NOTE: Supervisor MUST be informed as soon as inadequate staffing situation is known. By filling out and signing this form, you understand that the form and the information it contains may be shared with management in order to address the situation.
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Date: *
MM
/
DD
/
YYYY
Unit: *
Name of Supervisor Notified: *
Incident Report Number, If Filed:
Reason for Short Staffing:
Unit Specialty:
Unit Capacity:
Patient Census on Shift Start:
Patient Census At Time of Dispute:
Describe Assignment and Acuity:
Outcomes of Inadequate Staffing
Number of Staff at Time of Objection (RNs)
Number of Staff at Time of Objection (LPNs)
Number of Staff at Time of Objection (Ancillary)
Number of Staff at Time of Objection (Techs/Professionals)
Number of Staff Requested to Provide Proper Coverage
Signatures
We, the undersigned nurses and/or professionals, support the above documentation. As a result of this inadequate staffing, our patient(s) did not get the best care possible.
Signatory 1
Signatory 1 - Email Address
Signatory 2
Signatory 2 - Email Address
Signatory 3
Signatory 3 - Email Address
Signatory 4
Signatory 4 - Email Address
Signatory 5
Signatory 5 - Email Address
Signatory 6
Signatory 7
Signatory 8
Signatory 8 - Email Address
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