Observations gone wild!
At night, staff use this tool to check respirations without waking patients.
What is a flashlight?
This acronym refers to sexually acting out behavior and must be documented and reported.
What is SAO?
When in doubt, you do this with concerning behavior, every single time.
What is notify the nurse?
All entries in the medical record must include these three things.
What are date, time, and signature?
STOP & COUNT is especially important before this staff activity.
What is transitioning patients?
Observing a patient within arm’s length at all times, including toileting and showers.
What is 1:1 observation?
An RN can start precautions, but changing or stopping them requires this.
What is a provider order?
The proper way of correcting an error in the medical record? Hint hint....it isn't using white out or scribbles....
What is one line through the error, YOUR initials, the date, and the time.
Leaving your assigned patient without handing off this item is a policy fail.
What is the observation clipboard/sheet?
In addition to the patient observation sheet, what are the two communication forms (tools) used at admission for proper handoff
What is….
The high risk indicator form (the purple) and the SBAR.
late at night, shower time, and shift change all share this label.
What are high-risk times?
What color can written documents be completed in?
What is black or blue ink....NOT marker.
Patient observations with perfect times but no hallway presence raise concerns about this.
What is falsification or non‑compliance?
This communication tool stands for Situation, Background, Assessment, Recommendation.
What is SBAR
This high‑risk precaution often comes with unstable vitals, detox concerns, or a rapid response call.
What is medical risk?
This section of the medical record summarizes the patient’s stay and condition at discharge.
What is the discharge summary?
Leadership checks observation compliance not just in person, but using this technology.
What is camera surveillance?
Name the 7 high risk precautions
What are…
Suicide/Self Harm
Homicide/Assault/Aggression
SAO - V
SAO - A
Medical Risk
Fall Risk
Elopement Risk
A patient touching others, touching themselves, or pushing boundaries puts them in this high‑risk bucket.
What is sexually acting out?
This type of order must be read back, spelled out if sound‑alike, and signed within the required timeframe.
What is a telephone (or verbal) order?
Name the admission assessments by discipline and include the timeframe they MUST be completed in.
The initial treatment plan (admitting RN) - 8 hours of admission
The initial nursing assessment (admitting RN)- 8 hours of admission
PAA - (Provider) within 24 hours of admission
H&P (Medical) within 24 hours of admission
Psychosocial Assessment (Clinical Services) - 72 hours from admission
Master Treatment Plan (Treatment Team) - 72 hours from admission
Rec Therapy Assessment (RT) - 72 hours from admission