Providence Home Health and Hospice Staffing Request & Documentation Form (SRDF)

SRDF Process

Oregon Nurses Association has provided a means by which nurses at Providence Home Health and Hospice can report when nurse staffing on their unit/shift is insufficient and/or unsafe. The report is part of the ethical obligation of nurses to report when provision of “safe patient care” is not supported.

When a nurse is faced with staffing which is imminently or potentially unsafe according to the various causes of unsafe staffing, it is intended that the nurse

a) Notify someone in the chain of command,

b) Ask for additional staff, and

c) Ask for a response in a reasonable period of time, e.g., minutes, hours.

At the end of the shift, or within two business days, the nurse completes the form.

Filing an SRDF

The nurse should complete the following form. Upon completion, the nurse will receive a confirmation of submission email with a final copy of the completed SRDF form. This will also submit the form with ONA and the PNCC chair.

These reports are not confidential and may be disclosed by ONA and its staff. This may include providing copies of your report to the Oregon Health Authority, staffing committee members, to hospital administration, in testimony at legislative hearings, in briefings of legislators or regulators who are involved in this work and to others who ONA deems appropriate. You should NOT include any patient information in your report that might violate HIPAA regulations.

The nurse should then forward the form and file it with their nurse manager/supervisor.

If you have any questions, please contact ONA at Practice@OregonRN.org.

Incident Details

Name(s) of Submitting Nurse(s) *

Email Address of Primary Submitting Nurse *

Confirm Email *

Date of Incident * +

Branch/Location *

Specialty *

Role *

Shift *

Scheduled Shift Length *

Datix filled out? *

Yes

No

Did you notify someone in the chain of command? *

Yes

No

Name of person notified *

Date and time of notification *