BFN Outpatient CFSS/ADO Form Please enable JavaScript in your browser to complete this form.Your Name(s) *Clinic Setting *Date *Day of the Week *Cost Center *Length of scheduled shift: *Number of actual hours worked: *Manager's Name *As a patient advocate, in accordance with the Nurse Practices Act, this is to confirm that I/we notified you that in my/our professional judgment, my/our workload is unsafe and places my/our patients at risk. I have been mandated to provide care and do not want to abandon my patients. As a result, the facility is responsible for any errors or incidents that take place.NOTIFICATION GIVEN (You must notify your manager / supervisor at the time of need or concern) Manager / Supervisor *Time: *Response: *FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING CARE (Check all that apply) 1. Lack of experience / trainingFloat NurseOrienting Nurse2. Scheduled staff not replacedUnfilled positionSick TimeVacationEmergency ResponderWellness RNWeekend clinic coverage3. Lack of ancillary helpReceptionMA4. Staffing situation posed an actual or potential threatInjuryStressViolence5. Unable to delegate / perform / supervise safely due to needs greater than staff availableInjuryStressViolence6. MORE FACTORS AFFECTING ABILITY TO PROVIDE SAFE NURSING CAREMissed breaks and/or mealsSkill mix of staff inappropriateRequired to stay beyond shift7. OTHER FACTORS NOT COVERED ABOVE:STAFFING PROVIDED WAS NOT ADEQUATE TO ADDRESS PATIENT NEEDS RELATED TO (check all that apply)High patient volumeHigh patient acuityDELAYS + COMPROMISES IN PATIENT CARE NECESSITATED BY STAFFING SITUATION (Check all that apply):Timely triageDelay in care / rooming / HPIMedication reconciliationPatient assessmentPatient educationPrescription refill ordersCare coordinationTeam communication delaysProcedures: dressings / staple removal / lab-based med adjustments / foot care (...)DocumentationOther Delays + Compromises Not Covered Above:Brief Statement of the Problem: *Number of staff you actually had:RN, LPN, MA...Number of staff you needed in your judgmentRN, LPN, MA...Number of Ambulatory Resource Nurses requested:Number of Ambulatory Resource Nurses deployed:Who determines staffing?Manager/Practice supervisorStaffing officeDirector of NursingPlease Provide Additional Information Here:Submit