Concern For Assignment Form - Oklahoma Nurses Association Page 2
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2Factors influencing acuity: Check all that apply and the number of patients per intervention
On ventilators __
Receiving blood products __
Receiving titrated drips/chemo/TPN
__
Complete care __
Isolation __
Restraints __
<2 hours post op __
Vital signs/assessments <q1hr __
Other ___________
Suicide precautions __
Psychosocial needs ______
Section 4: Patient Care Staffing Profile
RN
LPN
Aide
Ancillary
Start of shift
End of shift
Additional Comments:_________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Section 4: Actions taken to remedy situation (use space to document times, names, other details)
Call in additional staff ____________________________________________________
Ongoing communication with supervisor during shift _____________________________
Reprioritized during shift __________________________________________________
Close beds/divert ________________________________________________________
As a patient advocate, I have notified you that, in my professional judgement this assignment is unsafe and places the
patient and /or staff at risk. I indicate my acceptance of this assignment is with stated concerns. It is not my intention to:
1.) refuse to accept the assignment and thus raise questions of meeting my obligations to the patient, or of
2.) refusal to obey an order which was given. However, I hereby give notice to my employer of the above facts and
indicate the reasons listed.
__________________________________ ___________________________ ________________
RN Signature
Print Name
Date
Section 5: To be completed by nurse to document follow up by organization or individual.
Actions taken to revise staffing:
Call in prn staff
Negotiated appropriately with physicians of stable
patients to change
“Traded” staff with other units to enhance mix
Changed mode of care (from total patient care to
Obtained overtime approval for staff to work over
team)
Pulled staff from other units
frequency of vital signs and other interventions
Request staff to trade shifts or days of work
Additional training to prepare staff to handle
situation
Other _______________ _____________________________________________
Recommendation/Outcome:
________________________________________________________________________________________________
________________________________________________________________________________________________
Date ___________________ Time _____________________ Initials
Workplace Advocacy……..building bridges to understanding
For more information, or assistance with workplace issues, contact the
Oklahoma Nurses Association at (405)840-3476.
Revised 10/00
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