Cdph530State of California-Health and Human Services Agency California Department of Public Health NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET CDPH 530 Rev (01/11) .FACILITY 2 3 SHIFT START TIME (HH:MM
AM/PM___ ______________ 7.ASSIGNMENT EMPLOYEE NAME DISCIPLINE SHIFT START/ END MEAL BREAK START/END
who are primarily engaged in duties other than nursing services that provided nursing services during the patient day are recorded and their nursing hours to be included in Nursing Hours Per Patient Day are accounted for with an original DIRECTOR OF NURSING/DESIGNEE SIGNATURENURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET Direct caregivers not captured in payroll records must capture their nursing hours on this form.This includes nursing management, supervisors, registry, contract, and corporate staff.
For example, this may apply but not be limited to, the nursing hours provided by such employees as a Director of Nursing in a facility with 60 or moreproviding nursing services beyond the hours required to carry out the duties of these positions.
Hours of nursing services provided by cross-trained staff who are otherwise regularly assigned to departments such as medical records, housekeeping, dietary or laundry, must be captured on this form.
Documentation must delineate the time spent on nursing services.
Failure to provide this information will result in the exclusion of all service hours foThe Nursing Staffing Assignment and Sign-In Sheet must be legible.All employee names must be include both first and last name
Nursing Staffing Assignment And Sign-in Sheet
The Nursing Staffing Assignment and Sign-In Sheet must be legible. All employee names must be ... CNA, NA, Psych Tech). Enter the employee’s exact shift start (web.missouri.edu)
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Corrections and modifications must be completed on the Nursing Staffing Assignment and Sign-In Sheet to document employee absences, substitutions, and/or schedule changes.
Legible pen/ink changes are acceptable.Each direct caregiver included on the Nursing Staffing Assignment and Sign-In Sheet must provide an original, written signature next to their printed name.This signature verifies the employee was present in the facility, provided nursing services, and actually worked the hours acceptable.Only the employee that worked the nursing assignment may sign for him/herself.
The form must be signed by the Director of Nursing or his/her designee verifying the information on the Nursing Staffing Assignment and Sign-In Sheet is complete, true and accurate.
Enter the facility name.
Enter the date of the patient day in MM/DD/YY format.
Enter the name of the person who has Director of Nursing responsibility for the day.
Circle the appropriate shift: one, two or three.
Enter the shift start time in HH:MM AM/PM format.
If applicable, enter the name of the specific location in the facility for the patient assignments.Record only direct caregivers not otherwise captured in payroll records.Enter the specific patient assignment and the employees name responsible for the patient assignment.
Enter the employees discipline (RN, LVN, CNA, NA, Psych Tech).Enter the employees exact shift start and end time.Enter the start and end time of the employees meal breaks.The employee must
At the conclusion of each patient day, the Director of Nursing or his/her designee shall sign the form verifying the nursing assignments are true and accurate and that all assignments are accounted for with an employee signature, or state a reason why the assignment was vacant.CDPH 530 Rev (01/11).
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