Safe harbor quick form

N3375 Health Policy & Legal Aspects

UTA_email_logo

Module 4: Reflection Assignment – Safe Harbor

Submit by 2359 (CT) Saturday of Module 4.

Name:

Date:

Overview: Safe Harbor

Due to staffing shortages and the unpredictability of hospital needs, nurses are sometimes asked to take on assignments outside their normal routines. As a healthcare professional, you must understand your options when asked to take on such assignments, the risks associated with accepting some assignments, and the protections afforded you by the law. Reflect upon your learning about the Safe Harbor protection as well as any experiences you have had in this realm. Then follow the instructions to download and complete Safe Harbor forms based upon a fictitious scenario.

Refer to your course readings and lectures as you complete the assignment.

NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor Comprehensive forms available electronically, download and complete them instead of the Texas forms. Follow all other directions as stated.

Performance Objectives:

· Explain and apply appropriate options regarding acceptance or rejection of assignments, including the use of Safe Harbor.

Rubric

Use this rubric to guide your work on the assignment, “Safe Harbor.”

Task

Accomplished

Proficient

Needs Improvement

Part 1

Complete Safe Harbor forms.

(Total 50 points)

Completes both forms correctly using information from the scenario. All forms copied and pasted onto template and submitted on time.

(50 points)

Completes one form correctly using information from the scenario. Forms not copied and pasted on template or submitted separately/10 pts deducted

(40 points)

Does not correctly complete any forms using information from the scenario.

(25 point)

Part 2

Reflect upon completion tasks.

(Total 50 points)

Clearly and correctly answers all three reflection questions.

(50 points)

Answers at least two reflection questions.

(40 point)

Fails to answer reflection questions

(0 points)

Part 1: Completing Safe Harbor Forms

1. Type http://www.bon.state.tx.us/practice/safe.html into your address bar.

NOTE: If your state has its own versions of Safe Harbor Quick and Safe Harbor Comprehensive forms available electronically, download and complete them instead of the Texas forms. Follow all other directions as stated.

2. Download the Quick and Comprehensive Forms

a. Click on the title of the form you wish to download.

b. On the Toolbar, select File, then Save Page As, and save it to your desktop or My Documents.

c. Open the pdf file from where you saved it.

d. On the Toolbar, select Edit, Copy File to Clipboard.

e. Position your cursor in this document below the scenario, then select Edit, Paste. (The form will lose some of its formatting, but you will now be able to type information into the blanks in this document. In your actual practice, you may follow this procedure, OR print the form and complete the hard copy form.)

3. Complete the forms in response to the scenario below, posing as the nurse described in the scenario. You will only fill out the follow: “COMPREHENSIVE REQUEST FOR NURSING SAFE HARBOR PEER REVIEW (SHPR)NOTE: ONLY SECTION I (pages 3-6) MUST BE COMPLETED BY THE NURSE WHEN INITIALLY INVOKING SAFE HARBOR”

You may have to fill-in some fictitious “facts” of your own to complete the forms.) You must only submit 1 assignment document, please paste the safe harbor forms in the assignment as instructed, and do not submit forms separately.

4. Everything must be copied and pasted onto this form.

Scenario: You currently work on a med-surgical unit in a medium-size hospital. The usual nurse-to-patient ratio is 1:5, which you feel is a heavy, but manageable, patient load. You arrive for your 7A to 7P shift and are told that, due to several RNs calling in sick with the flu, you will need to take nine patients. You question if additional staff is available from another unit, and you are told that administration is attempting to get help for the unit, but that none is available at this time. You then state, “I will take the assignment, but I must first claim Safe Harbor.”

[Paste the SAFE HARBOR QUICK REQUEST form here.]

[Paste the COMPREHENSIVE REQUEST FOR SAFE HARBOR form here.] Part 2: Reflection Questions

After you complete the two forms, answer these questions in the spaces provided.

1. How long did it take you to complete the Quick Form?

2. How long did it take you to complete the Comprehensive Form?

3. Who else must complete portions of the form(s)?

Submitting Your Assignment:

· Click Module 4: Assignment in the Module 4 folder.

· Scroll down to Assignment Submission. Click Browse My Computer and navigate to your Desktop where you saved your paper. Select the final version of your paper to upload from your computer.

· Click Submit at the bottom of the Assignment Submission screen and your saved document assignment will appear in the gradebook with a green exclamation point that alerts your Academic Coach that your assignment is ready for grading.

1

©2015 UT Arlington College of Nursing