Standardized Schedule on returning documentation and what should be documented on each form

To be submitted on a one time basis or if the client moves:

1) Demographic Form – includes the client’s personal information, health history etc – to be completed and sent to RNS within the first 3 visits

To be submitted once a year (in March):

1) Consent & Confidentiality Form – ensure the client / guardian consents to care – to be completed on first visit and then each year in March
2) Master Signature Sheet – here you will sign your full name and initials, this is the only place you will now need to complete a full signature – to be sent to RNS each March

To be completed Every 3 months (in March, June, September & December):

1) Braden Scale – complete the assessment laid out in the form
2) Care Report – For the Private client’s, this will be due within the first month of starting care, and then every 3 months (in March, June, September & December)
3) Diabetic Record – if your client requires you to check blood sugars, please document this here (send in to RNS every March, June, September & December)
4) Febrile Respiratory Illness Assessment – determine if the client has travelled outside of Canada, or been in contact with someone who has (Notify RNS IMMEDIATELY if this has occurred) (send form in Q3months)
5) Head –to-Toe Assessments – please complete all necessary tick boxes to provide information on your client (please note adults and pediatrics are on the same form, so ensure to use the appropriate boxes) to be completed on initial visit and then every March, June, September & December
6) Home Safety Assessment and Falls Risk – no changes from the previous form to be completed on initial visit and then every March, June, September & December
7) Infusion Therapy – complete this form ONLY if the client is receiving infusion therapy of any kind
8) MAR, PRN MAR and Narcotic Sheet – complete and send into RNS every March, June, September & December
9) Physician’s Orders – this form is if you receive verbal or telephone orders from the doctor during your shift
10) Progress Notes – This is where you will document your assessment each shift and all of the care you provided, you will notice that Vital Signs, Intake and Output, Ventilator Settings and Tube feeds are now on the back

To be completed on a PRN basis:

1) Chart Thinned – complete only when you thin the chart – this will be every March, June, September & December, and whenever else you feel it is necessary to thin the chart
2) LHIN CSR – to be completed on the due dates outlined by the LHIN – it will now be your responsibility to track when these are due – it will be outlined at the start of care for new clients, Collette will no longer be sending reminder emails.
3) Communication Forms – please use these only when you wish to communicate a change in the client’s status, orders, wishes of parents etc to your fellow nurses, you are not require to complete this each shift
4) Transfer to hospital – complete when you call 911 to send client to hospital – send to RNS as soon as possible
5) Wound Care – only to be completed when the client has a wound we are caring for, our you notice a wound beginning (send in Q3months March, June, Sept, December if the client has a wound)
6) Palliative Care Resources – if you client is palliative and an Adult, please complete the ESAS tool and ESAS Log each shift & provide the family with the resources document. For Children please complete the SSPedi each shift – if the child is over 8 and verbal they can complete themselves, if not please have the parents complete.