student orientation forms nursing students pih health ...roll belt demonstrated correct application...

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Student Orientation Forms

Nursing Students – PIH Health Hospital - Whittier

NURSING STUDENT

CONSENT FOR RELEASE OF INFORMATION

______________________________________ ___________________________ Name (Last, First, MI) Date of Birth The School may not disclose information contained in student’s records without the student’s written consent except under certain conditions. The employee’s record may be released to a third party by providing a written authorization or consent. Consent for Release of Information: I hereby give my consent for the following information to be released to PIH HEALTH (upon the hospital’s request) specifically for the calendar year: ____________________________.

1) Background Check 2) Immunization Records 3) TB Test Results 4) Drug Screen Results 5) Physical Examination by Licensed Provider

__________________________________ ________________________

Signature Date

Photocopies of this authorization may be made and used as duplicate originals. This authorization shall remain valid for as long as this Agreement remains in effect and/or School provides services to Hospital, whichever is longer.

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PIH HEALTH HOSPITAL WHITTIER, CALIFORNIA EDUCATION DEPARTMENT

UNIT/DEPARTMENT SPECIFIC ORIENTATION - Nursing Student

Student to initial when completed

UNIT NAME: _____________________

Department Overview:

Location of Departmental/Hospital Policies on Intranet

Review of unit specific policies and procedures as appropriate

Identify unit/department chain of command

Physical Set-up/Work Environment

Office equipment review / Identify location of supplies and forms

Review physical set-up of unit/department and review telephone system, beeper, VOCERA

Safety Issues

Identify location of fire exits and extinguishers and review fire and disaster plan

Workflow

Identify shift responsibilities and assignment including assigned resource person/buddy

Review documentation responsibilities and review admission/discharge processes (clinical only)

Human Resources Items

Meal breaks; identification badge visible and above waist; dress code

I acknowledge that I have been oriented to the following specific information. ____________________________________ _______________________________ _________________________ Student Signature/Initials Evaluator Signature Evaluator Print Name

Name_______________________________________ School______________________________________ Date________________________________________

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COMPETENCY ASSESSMENT: RESTRAINTS

Assessment Code (A.C.): Method of Evaluation: 1 = Performs skill independently & completely D = Return Demonstration 2 = Performs skill but requires supervision O = Clinical Observation 3 = Can verbalize theory/how to perform skill, V = Verbal Feedback

but has had minimal opportunity to practice skill

KNOWLEDGE BASE: Assessment Code

Method of Evaluation

Finds and reads Policy No. 87200.604 D O V

Assessment Code


Restraint Application Clinical Staff / Ancillary Support Staff

Roll Belt

Demonstrated correct application of the roll belt D O V

Demonstrated correct technique for securing the roll belt D O V

Demonstrated correct technique for releasing the roll belt buckles D O V

Vest (Bed) Restraint

Demonstrated correct application of vest restraint D O V

Demonstrated correct technique for securing vest ties D O V

Demonstrated correct technique for quick release ties D O V

Extremity Restraint

Demonstrated correct application of restraint to extremity D O V

Demonstrated correct technique for securing extremity restraint D O V

Demonstrated correct technique for quick release of extremity restraint D O V

Verbalized that hard restraints will be used in CCC and ED only D O V

Finger Control Mitt Restraints

Demonstrated correct application of Mittens per manufacture instruction D O V

Demonstrated correct technique for securing mittens D O V

Demonstrated correct technique for quick release ties D O V

Demonstrated application to immobilize hand or fingers (untied) D O V

Torso (Chair) Restraint

Demonstrated correct application of the Torso Support D O V

Verbalized process for choosing correct restraint size D O V

Verbalized patient instruction as to sit with hips against the chair back D O V

Demonstrated wrapping chest strap around patient torso D O V

Demonstrated securely hooking chest straps together behind chair back D O V

Demonstrated bringing shoulder straps over patient shoulders and chair back and crossing in an “X” to secure to chest strap

D O V

Demonstrated checking for restraint fit using the flat of the hand D O V

I acknowledge that I have read & completed the competency criteria support document. ____________________________________ _______________________________ _________________________ Student Signature Evaluator Signature Evaluator Print Name

Name_______________________________________ School______________________________________ Date________________________________________

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COMPETENCY ASSESSMENT: GAIT BELT



Gait Belt Competency Assessment Code


Demonstrated appropriate application of gait belt D O V

Verbalized indications for use of gait belt D O V

Demonstrated appropriate positioning and guarding techniques for utilization of gait belt D O V

Demonstrated or verbalizes the appropriate infection control technique with gait belt D O V


Name_______________________________________ School______________________________________ Date________________________________________

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Hand Hygiene

Checklist



Assessment A.C.

Method of Evaluation Comments

D O V

Performed hand hygiene before patient contact.

Pushed long sleeves above wrists

Inspected surface of hands for breaks or cuts in skin or cuticles.

Implementation: Hand washing using plain or antimicrobial soap and water

A.C.


Comments

D O V

Stood in front of sink, kept hands and uniform away from sink surface. (If hands touched sink during hand washing, repeated hand washing).

Turned on water. Turned faucet on, or pushed knee pedals laterally, or pressed pedals with foot to regulate flow and temperature.

Avoided splashing water against uniform.

Regulated flow of water so that temperature was warm.

Wet hands and wrists thoroughly under running water. Kept hands and forearms lower than the elbows during washing.

Applied a small amount of soap or antiseptic, lathered thoroughly.

Performed hand hygiene by using plenty of lather and friction for at least 15 seconds. Interlaced fingers and rubbed palms and back of hands with circular motion at least 5 times each. Kept fingertips down to facilitate removal of microorganisms.

Noted that areas underlying fingernails are often soiled. Cleansed them with the fingernails of other hand and additional soap, or cleansed with a disposable nail cleaner.

Policy 100.87500.614

Name: ________________________________

School: _____________ Date: _____________

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Hand Hygiene (cont.) A.C.


Comments

D O V

Rinsed hands and wrists thoroughly, kept hands down and elbows up.

Dried hands thoroughly from fingers to wrists with paper towel, single-use cloth, or warm air dryer.

Discarded paper towel, if used, in proper trash receptacle.

Turned off hand faucet using a clean, dry paper tower, and avoided touching handles with hands. Turned off water with foot or knee pedals (if applicable).

If lotion applied to hands, used the facility-provided lotion available. Avoided petroleum-based lotions.

Implementation: Hand antisepsis using an instant alcohol waterless antiseptic rub

A.C.


Comments

D O V

Dispensed ample amount of product into the palm of one hand.

Rubbed hands together, covered all surfaces of hands and fingers with antiseptic rub.

Rubbed hands together until the alcohol is dry.

Allowed hands to completely dry before gloves applied.


________________________________ __________________ _____________ Student Name: School: Date:

Copyright © 2006 - 2015 Elsevier Inc. All Rights Reserved.

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COMPETENCY ASSESSMENT: PPE - ISOLATION PRECAUTIONS



PLANNING Assessment Code


Chosen barrier protection that is appropriate for the type of isolation. - Contact/MDRO: Standard precautions plus gloves and gown - Droplet/Respiratory: Standard precautions plus mask - Airborne: Standard precautions plus an N-95 respirator

D O V

Gathered equipment D O V

IMPLEMENTATION

Performed hand hygiene D O V

Applied/Don a gown when giving direct patient care. - Ensured the gown covers the torso from the neck to knees, arms to the end of

the wrists and wraps around the back. - Pulled the sleeves of the gown down to the wrist - Fastened the gown securely at the back of the neck and the waist

D O V

Applied /Don either a surgical mask or a fitted N-95 respirator around the mouth and nose. (if indicated) - Secured the ties or elastics at the middle of the head and neck or the elastic

ear loops around the ears. - Fitted the flexible band to the nose bridge. - Ensured the mask fits snug to the face and below the chin.

D O V

Applied /Don eye protection (goggles or face shield), if needed, around the face and eyes. Adjusted to fit.

D O V

Applied /Don gloves when giving direct patient care. - Cuff of glove brought over the edge of the gown sleeves.

D O V

Identified patient D O V

Explained reason for isolation to patient D O V

Kept patients’ door open D O V

Performed patient care D O V

Removed PPE (personal protective equipment) prior to leaving patient room with the exception of the N-95 respirator. D O V

Removed/Doff gloves - Using gloved hand, grasped the palm area of the other gloved hand and

peeled off the first glove. - Held the removed glove in the gloved hand. - Slid the fingers of the ungloved hand under the remaining glove at the wrist - Peeled the second glove off over the first glove. - Discarded gloves.

D O V

Name_______________________________________ School______________________________________ Date________________________________________

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PPE - ISOLATION PRECAUTIONS COMPETENCY (CONT.)

Assessment Code


Removed/Doff gown (Front and sleeves are contaminated) - If hands got contaminated during gown removal, immediately washed hands

or used alcohol based hand sanitizer. - Unfastened gown ties, taking care that sleeves didn’t contact your body when

reaching for ties. - Pulled gown away from neck and shoulders, touching inside of gown only. - Turned gown inside out - Folded or rolled into a bundle and discarded in a waste container.

D O V

Removed/Doff eye protection from the back by lifting the head band or ear pieces. D O V

Removed/Doff mask. D O V

Performed hand hygiene D O V



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COMPETENCY ASSESSMENT:

NOVA BLOOD GLUCOSE MONITORING

Nova Glucometer Cleaning and Disinfecting

Assessment Code: Method of Evaluation:________________

1 = Performs skill independently & completely D = Return Demonstration

2 = Performs skill but requires supervision O = Clinical Observation

3 = Can verbalize theory or how to perform skill, V = Verbal Feedback


PRE-ASSESSMENT Assessment

Code

Evaluator

Initials

Method of

Evaluation Checked Quality Control and battery status D O V

Performed quality control (if needed)

Verbalized policy on “dating” for all test strips, notes expiration

dates on control and strips.

Once opened, test strips are stable up to 6 months

D O V

D O V

D O V

ASSESSMENT and PLANNING Assessment

Code

Evaluator

Initials

Method of

Evaluation Reviewed physician’s order D O V

Explained procedure to patient D O V

Gathered needed supplies D O V

IMPLEMENTATION Assessment

Code

Evaluator

Initials

Method of

Evaluation Performed hand hygiene D O V

Donned on gloves D O V

Identified patient using 2 identifiers (name and MR#) D O V

Turned meter on D O V

Scanned operator ID badge or uses keypad to enter manually and

presses “Accept”

D O V

Selected “patient test” screen and presses “Accept” D O V

Scanned the strip lot number and “Accepts” if correct D O V

IMPLEMENTATION (CONTINUED) Assessment

Code

Evaluator

Initials

Method of

Evaluation

Name_______________________________________ School______________________________________ Date________________________________________

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Scanned patient armband barcode by pressing the “Scan” key on the

screen and positioning bottom of the meter above the patient’s

armband bar code. If scanning fails, enters pt. account (visit)

number manually. Presses “Accept” when correct patient ID

appears on the screen

D O V

Placed the test strip into the meter as shown on the screen D O V

Selected puncture site, cleanse site with alcohol wipe, allows to dry D O V

Punctured the fingertip of either the middle or ring finger, or infant

heel with lancet

D O V

Squeezed the finger to form a drop of blood. Wipes off the first drop

with a gauze

D O V

Placed a drop of blood on the test strip while the meter is in a

horizontal position

D O V

Applied gauze to skin to cover puncture site D O V

Viewed result on screen and “Accept” or “Reject” the result. The

result will appear in 6 seconds.

D O V

Removed test strip when analysis is complete and dispose of in

regular trash

D O V

Disposed Lancet in sharps container D O V

Verbalized patient testing process in isolation room D O V

EVALUATION, RECORD AND REPORT Assessment

Code

Evaluator

Initials

Method of

Evaluation Evaluated results and follows doctor order in coverage D O V

Documented results in eMAR D O V

Identified critical ranges and states corrective action by pressing

“Comment” key and choosing a comment that corresponds to

the patient’s current situation.

D O V

Followed nursing procedural protocol for hypoglycemic or

hyperglycemic follow up if needed

D O V

Documented date, time and person notified of the critical value D O V

Screened will display “Hi” for result over 600 mg/dL. Repeat test if

result does not correlate with patient medical condition.

D O V

QUALITY CONTROL TESTING Assessment

Code

Evaluator

Initials

Method of

Evaluation Pressed the QC soft key from the patient test screen

Performed high and low solutions every 24hrs or if meter is dropped

Once the high or low solutions are opened, the solutions are good for

3 months

D O V

D O V

D O V

Scanned the Strip Lot Number barcode

Pressed the “Scan” key

Pressed the “Accept” key if the lot number is correct

D O V

D O V

D O V

Scanned the QC lot number

Selected from the QC Lot List screen (press the List button) or

Scanned the barcode (press the Scan key)

Pressed the “Accept” key if the lot number is correct

D O V

D O V

D O V

Inserted Test Strip at the top of the meter in the test strip port D O V

QUALITY CONTROL TESTING (CONTINUED)

Assessment

Code

Evaluator

Initials

Method of

Evaluation

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Mixed gently the Stat Strip Glucose Control Solution before each

use. Discard the first drop of control solution from the bottle to avoid

contamination.

D O V

Once the meter completd the test, the QC results will be displayed

along with a PASS or FAIL

To add a comment to the result, pressed the “Comment” key

To accept the result, pressed the “Accept” key

D O V

D O V

D O V

CLEANING and DISINFECTING METER

CLEANING Assessment

Code

Evaluator

Initials

Method of

Evaluation Removed test strip from the meter D O V

Placed glucometer on a flat surface

Donned gloves and removed a fresh germicidal wipe from the

canister

D O V

Wiped the external surface of the meter thoroughly with a feesh

germicidal disinfecting wipe

D O V

Wet contact time not needed on this step D O V

Discarded used wipe into an appropriate container D O V

DISINFECTING Assessment

Code

Evaluator

Initials

Method of

Evaluation

Used a new fresh germicidal wipe, thoroughly wiped the surface of

the meter (top, bottom, left, and right sides) a minimum of 3 times

horizontally followed by 3 times vertically avoiding the bar code

scanner and electrical connector

D O V

Wiped gently the surface area of the test strip port making sure that

no fluids enters the port

D O V

Do not allow liquid to enter the strip port connector or allow pooling

of liquid on the touch screen. If liquids does get into the strip port or

connector, immediately dry the components with a dry cloth or

gauze

D O V

Ensured the meter surface stayed wet for 2 minutes for purple top

and 4 minutes for orange top and is allowed to air dry

D O V

Discarded used wipe(s) and gloves into an appropriate container D O V

Performed hand hygiene and donned fresh gloves prior to testing on

the next patient if applicable

D O V

DOCKING D O V

Docked the meter in a Data Docking Station to automatically

upload stored meter data, download updated setup information,

and to charge meter battery.

D O V

I acknowledge that I have read & completed the competency criteria support document.

_____________________________ ____________________________________

Employee Signature Evaluator Signature/ Initials

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PIH HEALTH HOSPITAL NOVA BLOOD GLUCOSE MONITORING QUIZ

Name:_________________________________ School: _________________________ Date:___________

Circle the correct answer(s). 1. Once opened, the test strips are stable for up to _____ months. 2. What should you do if the meter scanner will not scan the patient’s armband barcode? a. Manually input patients 9 digit medical number b. Manually input patients 8 digit account number without leading zeros c. Manually input patients 12 digit account number d. Manually input patients 5 digit medical number without leading zeros 3. What should you do if quality control result falls outside the expected range? a. Press the “Comment” key and select the appropriate comments b. Repeat that level of control c. Put the meter back in the docking station d. A & B 4. Quality Control should be performed: a. Once a week b. Once every 24 hours c. If the meter was dropped d. B & C 5. What should you do if the patient result is critical? a. Press “Comment” to select appropriate action b. Turn off meter to avoid entering comment c. Repeat test if critical result does not correlate with patient medical condition d. A & C 6. If the meter displays “Hi” it indicates the patient result is greater than

a. The patients result is 600 mg/dL b. The patients result is 400mg/dL c. The patients result is 1000mg/dL

7. In order for the patient’s results to be captured and billed what must be done? a. Press the Accept key b. Nothing, it automatically gets downloaded c. Press the Continue key 8. Docking the meter: a. Uploads the data b Downloads information c. Charges battery d. All answers apply 9. To prevent contamination of glucometer a. Testing should be done at a horizontal angle b. Testing should be done at a vertical angle c. Testing should be done at any angle 10. If the back cover comes off the glucometer a. Tape cover back on glucometer and it will continue to work b. Call Bio Med c. Look at battery, if battery is expanded take to laboratory and exchange for new battery d. Take to laboratory and use a loaner

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11. Glucometer cleaning and disinfection is a 2 step process. To ensure proper disinfection, it is important to clean the meter prior to disinfecting the meter.

a. True b. False

12. The proper process for CLEANING the glucometer (Step 1) is as follows:

a. Don gloves, wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting

wipe. Wet contact time is NOT needed for this step. Discard the used wipe into an appropriate

container.

b. Don gloves, wipe the external surface of the meter thoroughly with alcohol wipes. Wet contact time

is 4 minutes for this step. Discard the used wipe into an appropriate container.

c. Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting wipe. Wet

contact time is not needed for this step. Discard the used wipe into an appropriate container.

13. The proper process for DISINFECTING the glucometer (Step 2) is as follows: a. After CLEANING the glucometer, use a new, fresh germicidal wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port. Ensure the meter surface stays wet (2 minutes when using purple top wipes) and is allowed to air dry. b. Thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port. c. After CLEANING the glucometer, use a new, fresh germicidal wipe to thoroughly wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 2 times horizontally followed by 2 times vertically avoiding the bar code scanner and electrical connector. Gently wipe the surface area of the test strip port making sure that no fluid enters the port.

14. What is the wet contact time for CLEANING and DISINFECTING the glucometer? a. There is a 2 minutes wet contact time for both cleaning and disinfecting

b. There is no wet contact time for cleaning. There is a wet contact time for disinfecting (2 minutes using purple top wipes and 4 minutes when using bleach wipes).

c. There is no wet contact time for both cleaning and disinfecting. 15. How many times must you wipe the glucometer when disinfecting (Step 2)?

a. Wipe the surface of the meter (top and bottom) a minimum of 2 times horizontally followed by 2 times vertically avoiding the bar code scanner and electrical connector. b. Wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 6 times horizontally followed by 6 times vertically avoiding the bar code scanner and electrical connector. c. Wipe the surface of the meter (top, bottom, left, and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector.

16. Perform hand hygiene and don fresh gloves prior to testing each patient A. True B. False Score: ___/ 16 Answers are reviewed with student. _______________________________ _________________________ Evaluator Signature Evaluator Print Name

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COMPETENCY ASSESSMENT: MEDICATION ADMINISTRATION FOR STUDENTS


but has had minimal opportunity to practice skill 4 = Unable to perform skill

PROCEDURE Assessment Code


Reviewed physician orders closely for medications. Medication orders must be complete with name, dosage, frequency, route, date, time, and signature of the prescriber. All “PRN” orders must include indication for administration.

D O V

Patient height and weight must be entered in the computer. D O V

PREPARATION

Logged into EMD D O V

Located patient and access eMAR D O V

Verified patient D O V

Checked for allergies. D O V

Located scheduled medications due (time critical versus non time critical) D O V

PREPARING MEDICATIONS FROM OMNICELL (with Instructor or RN Preceptor)

Instructor/Preceptor logged into Omnicell D O V

Located patient by NAME D O V

Selected medication to be administered D O V

Performed 6 rights (right patient, medication, dose, route, time, and documentation) D O V

Proceeded to patient’s room D O V

PREPARING NARCOTIC MEDICATION (no waste)

Entered narcotic dose to be administered D O V

Removed medication(s) from Omnicell D O V

Proceeded to patient’s room D O V

PREPARING NARCOTIC MEDICATION (waste)

Entered narcotic dose to be administered D O V

Removed medication from Omnicell D O V

Wasted at this time with another RN and Instructor/Preceptor D O V

Documented waste in the Omnicell D O V

Proceeded to patients room D O V

PREPARING MEDICATIONS FROM PATIENT MEDICATION BIN

Located patient bin by ROOM NUMBER D O V

Selected medication to be administered D O V


Performed 2 RN dose verification if applicable D O V

Name_______________________________________ School______________________________________ Date________________________________________

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MEDICATION ADMINISTRATION FOR STUDENTS COMPETENCY (CONT.)

MEDICATION ADMINISTRATION IN PATIENT ROOM Assessment Code


Logged into eMD D O V

Located patient and access eMAR D O V

Verified patient by verbally confirming with the patient their name and through a second verification process by matching the patient name and medical record number on the eMAR with the patient’s wristband.

Reviewed patient’s allergies

D O V

D O V

Reviewed medication to be administered D O V


Accessed KBMA through eMAR D O V

Scanned patient wristband using the 2D barcode

Through KBMA, the correct patient is identified by scanning only the 2D barcode on the patient identification band worn by the patient

If the 2D bar code on the identification band cannot be scanned, notify primary RN

D O V

D O V

D O V

Scanned all medication (s) using barcode on mediation, pharmacy label or pharmacy flag label

Through KBMA, the correct medication is identified by scanning the barcode on the medication package while at the patient bedside.

D O V

D O V

Acknowledged alerts D O V

Administered medication D O V

Documented medication (s) administer in the MR D O V

Documented necessary assessment/data D O V

MISCELLANEOUS

Primary RN will be notified of any medication without a barcode, D O V

Crushing and cutting of tablets will occur at the patients bedside after first scanning the medication barcode.

D O V

Wasting of medications will occur in the medication room, with a licensed care provider as a wtiness.

D O V

Medications packaged in multi-dose contatiners will be stored with barcode labels provided by paharmacy and applied to syringe/medicaiton cup by the licensed care provider administering the medication.

D O V

Medications without a barcode or a barcode which cannot be scanned should be adminstered using the No Scan process in KBMA. The medication must be reported to the primary nurse who will then notify pharamcy immediately after for corrective actions.

D O V

All medications identified by the pharmacy, will be placed in the patient’s medication bin. All controlled substances will be locked up in the nursing narcotic storage/Omnicell container.

D O V



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Print Name: __________________________

Assigned Nursing Unit: _________________

Date: ______________________________

PRESBYTERIAN INTERCOMMUNITY HOSPITAL

WHITTIER, CALIFORNIA

EDUCATION DEPARTMENT

COMPETENCY – END USER

HOSPIRA PLUM A+® to PLUM 360® Device Updates (Software 15.02 and 15.1x)


Signature: _____________________________________________ Date: ________________

Self-Assessment Code/Preceptor Sign Off Code: Method of Evaluation: 1 = Performs skill independently & completely D = Return Demonstration

2 = Performs skill but requires supervision O = Clinical Observation

3 = Can verbalize theory or how to perform skill, V = Verbal Feedback


Assessment

Code

Evaluator

/Initials

Method of

Evaluation Understand go live and post go live logistics D O V

Review outside features of the device and demonstrate how to turn

on, start, stop, perform an audio silence with activation and

deactivation of “LOCK KEYPAD” feature

D O V

Review and understand battery information D O V

Demonstrate how to select your CCA D O V

Demonstrate how to program an infusion/medication in lines A & B D O V

Demonstrate how to clear volume infused D O V

Demonstrate how to change CCAs D O V

Demonstrate how to upload a new drug library D O V

Review common alarm conditions and demonstrate how to

troubleshoot common alarm conditions

D O V

Verbalize understanding that quick reference guides for pump use

and cleaning are located on the Education SharePoint page

D O V

Program a primary infusion with Standby (CCC ONLY) D O V

Demonstrate programming a bolus (for SW 15.10 only with ICU

Medical MedNet) (CCC, ED and Cardiac CCAs)

D O V


____________________________________ ____________________________________

Employee Signature Evaluator Signature / Initials

17


PRECEPTEE AGREEMENT

Dear Preceptee: We are pleased to have you here at PIH Health. Assisting in the growth and development of the next generation of nurse leaders is a very important commitment for our organization. Over time we have found the following guidelines ensure a valuable and positive learning experience for both our preceptees and PIH Health nursing preceptors. Please review the following and acknowledge your acceptance of these guidelines by signing below.

Strictly follow the RN preceptors work schedule. Do not seek additional hours with other nurses.

Notify preceptor in advance either the night before or no later than 2 hours before the shift begins (5:00am) if you will be calling off.

Arrive promptly and be prepared at 7:00am to begin your shift. Tardiness delays patient care and prevents you from receiving a thorough report with your preceptor. Tardy is considered 7:01am/pm.

Adhere to the PIH Dress Code, Policy #86500.718.

Cell phone, iPods, and other electronic devices will not be used in patient care areas. Such items will only be allowed in break areas such as the nurse’s lounge or patio areas. Please use Lexi-comp or Expert Advice for drug referencing needs.

If the student fails to adhere to any of the aforementioned guidelines the preceptor will counsel the student and the instructor will be notified.

If the student is unable to adhere to the preceptee guidelines following counseling by the preceptor and instructor, termination of preceptorship will be considered.

_____________________________________________________ Student Signature

Name_______________________________________ School______________________________________ Date________________________________________

18

STUDENT PRECEPTEES – EMERGENCY CONTACT INFORMATION

GENERAL INFORMATION Name

Address

City, State, Zip Code

Telephone Numbers: Home Phone: Cell Phone:

Company/School

Supervisor/Instructor Name: Phone:

EMERGENCY INFORMATION Notify/Relationship Contact Number

Notify/Relationship Contact Number

INSURANCE/MEDICAL CONTACT INFORMATION Medical Insurance Medical Record #

Policy # Contact Number

Physician Contact Number

Where non-emergent care is to be provided

MEDICAL INFORMATION Important Medical History:

Critical Allergies

Any additional information

RETURN TO EDUCATION DEPARTMENT IF YOU ARE A PRECEPTEE

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