Nursing Worksheet Form – Fill Out and Use This PDF

WORKLOAD MANAGEMENT SYSTEM FOR

NURSING - GENERAL WORKSHEET

ENTER DATE, RN INITIALS,

AND LAST FOUR SSN

ACUITY

SECTION I - CRITICAL INDICATORS (Continued)

POINT

CODE

VALUES

6. TREATMENTS/PROCEDURES/MEDICATIONS

(Continued)

55

Dressing - complex 30 mins x 1

4

56

Lab tests performed/collected on the unit x 3

2

57

Do EKG

2

58

Venipuncture, arterial puncture x 2

2

59

Medications - exclude IV - 3-11 trips or q3h - q8h

2

60

Medications - exclude IV - 12 trips or more or q2h

4

61

Irrigations or instillations x 4 or less

2

62

Restraints, 2 point, 4 point, Posey

2

63

Assist OOB chair/gurney and return, x 3

2

64

Assist to ambulate and return, x 1

2

65

Infant circumcision or phototherapy

2

66

Isolation mask, gown and gloves x 8

2

67

Chest tube insertion or lumbar puncture (assist)

4

68

Thoracentesis or paracentesis (assist)

4

69

Range of motion exercises x 3

4

70

New admission - assessment and orientation

12

71

Transfer - in-house (receiving unit only)

4

72

Accompany patient off unit 15 minutes

2

73

Accompany patient off unit 30 minutes

4

74

Accompany patient off unit 45 minutes

6

75

Other activities requiring 15 minutes

2

76

Other activities requiring 30 minutes

4

77

Other activities requiring 45 minutes

6

78

Each hour requiring continuous staff

attendance

8

7. RESPIRATORY THERAPY

79

Oxygen therapy or oxyhood

2

80

Incentive spirometer or C&DB q4h or x 6

2

81

IPPB or Maximist bid or x 2

2

82

IPPB or Maximist q6h or x 4

4

83

IPPB or Maximist q4h or x 6

6

84

Croup tent or mist tent

8

SUBTOTAL C POINT VALUE

ENTER DATE, RN INITIALS,

AND LAST FOUR SSN

ACUITY

SECTION I - CRITICAL INDICATORS (Continued)

POINT

CODE

VALUES

7. RESPIRATORY THERAPY (Continued)

85

Chest pulmonary therapy bid or x 2

2

86

Chest pulmonary therapy q6h or x 4

4

87

Chest pulmonary therapy q4h or x 6

6

88

Suctioning q4h or x 6

2

89

Suctioning q2h or x 12

4

90

Ventilator

10

91

Tracheostomy care x 3

4

8. TEACHING

92

Teaching - group - per hour

2

93

Teaching - individual - per 30 minutes

4

9. EMOTIONAL SUPPORT

94

Patient/family support (per 30 minutes)

4

95

Lifestyle modification (per 30 minutes)

4

96

Sensory deprivation - blind, deaf, retarded, etc.

6

97

Maximum points for emotional support

10

10. CONTINUOUS

98

Patient requiring 1:1 coverage all shifts

96

99

Patient requiring greater than 1:1 coverage

all shifts

146

SUBTOTAL D POINT VALUE

SUBTOTAL A POINT VALUE

SUBTOTAL B POINT VALUE

SUBTOTAL C POINT VALUE

TOTAL POINT VALUE

PATIENT ACUITY CATEGORY

SECTION II - ADDITIONAL DATA

1. ACUITY TABLE

2. TYPE OF PATIENT (X as applicable)

CATEGORY

POINTS

a. MED/

e. ANTEPARTUM/

0

O

SURG

POSTPARTUM

I

1 - 12

b. ICU

f. PEDIATRIC

II

13 - 31

III

32 - 63

c. NURSERY

g. PSYCHIATRIC

IV

64 - 95

V

96 - 145

d. NEONATAL ICU

VI

146 - 262