HIGHLANDS BEHAVIORAL HEALTH SYSTEM
POLICY AND PROCEDURE
SUBJECT:

Patient Observation Policy

POLICY NO.: PC-120

SECTION:

PC-PROVISION OF CARE

EFFECTIVE DATE: 03/01/07

DEPT:

CLINICAL AND NURSING

REVIEWED:

02/12/2013
REVISED:

02/10/2012,

03/23/2012

POLICY:
It is the policy of Highlands Behavioral Health System that ail patients are supervised, at a minimum,
every 15 minutes through the rounds/milieu observation process.

PURPOSE:
To ensure patient safety by observing and documenting patient location and behavior. This policy also
provides increased environmental safety by conducting regular environmental safety inspections and
checks of assigned treatment unit. To identify high risk or high alert behaviors through assessments
and implement other precautions as required.

PROCEDURE:

I. Precautions
1.

May be implemented by the RN with notification of the Psychiatrist with in a reasonable time

3.

period to obtain order for precaution.
Identify individual precautions communicate and document on Patient Observation Rounds
sheet.
May include but not limited to identified high risk/high alert behaviors obtained from

4.

assessments.
identified precautions require additional monitoring as identified on page 2 of the Patient

2.

Observation Rounds sheet.
II. Roles and Responsibilities
1

Intake:

a.
b.
c.
d.

e.

f.
g.

Review and update patient observation forms.
Clearly print employee name, job title and initials in the appropriate section(s) of the
patient observation form.
Observe each patient, a minimum of every 1 5 minutes and document observation on
the patient observation form
Perform rounds at staggered intervals and in a varying pattern or sequence to minimize
planned acting out opportunities.
Verify correct patient by:
i. ID band, patient photo, asking the patient to tell you his/her first and last name
and/or birth date, or have another staff member verify the patient identity.
Document patient location and behavior when the observation occurs on the patient
observation form.
While monitoring patients, ensure patients are:
i.
not entering rooms not assigned to them.

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h.

i.

ii.
not in rooms or areas that are designated "off limits" to patients.
When other staff assumes responsibility for the patient, (i.e. patient taken to unit from
intake) the patients observation check sheet should accompany them or the person
assigned to checks should document who accompanied the patient, the time the
patient left intake.
Be aware of times when your focus can be diverted:
i.
changes of shift
ii. codes
iii. crisis de-escalation
iv. visiting hours
v. unit staff meetings

2.

Charge Nurse/Nursing Supervisor/Team Leader:
a. Assigns responsibility for completion of patient observation and environmental safety
rounds at the beginning of each shift.
b. Documents the assignments on the unit staff assignment sheet.
c.
d.

Ensures the Patient Observation Rounds are occurring as ordered, 24 hours per day,
seven days a week.
Nurse/Unit Supervisor oversight of patient observation rounds is evident per
review/signature on Patient Observation Rounds sheets at a minimum of twice per shift.

3. BHA:

a.

Review and update patient observation forms. Reflect changes in individual patient
precautions levels, room or bed changes, new admissions and/or discharges as they

b.

Clearly print employee name, job title and initials in the appropriate section(s) of the patient
observation form.
Observe each patient, a minimum of every 1 5 minutes and/or according to
OBSERVATION Safety Precaution Level and document observation on the patient
observation form
Perform rounds at staggered intervals and in a varying pattern or sequence throughout the
unit to minimize planned acting out opportunities.
Verify correct patient by:
i. ID band, patient photo, asking the patient to tell you his/her first and last name
and/or birth date, or have another staff member verify the patient identity.
Document patient location and behavior when the observation occurs on the patient
observation form.
While monitoring hallways and patient care areas ensure patients are:
i.
not entering rooms not assigned to them.
ii.
not in rooms or areas that are designated "off limits" to patients.
iii. not left in treatment areas without direct staff supervision.
iv. are participating in their treatment by being where they are directed to be
v. are not sleeping or otherwise avoiding participation in treatment activities unless
approved by the charge nurse or doctor.
Observe patients on bed rest or when sleeping by:
i.
looking for the rise and fall of the chest,
ii.
counting at least three respirations, and
iii.
making sure that the patient has moved from his/her previous sleeping position
Visually observe patients when behind closed doors by:
i.
knocking on bedroom and bathroom doors,
ii.
announce that they are stepping into the room for rounds,

occur.

c.

d.
e.

f.
g.

h.

i.

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iii. open the door and visually observe the safety of the patient
When other staff assumes responsibility for the patient, (i.e. intake follow up, individual
therapy, session with physician, etc.) the patients observation check sheet should
accompany them or the person assigned to checks should document who accompanied
the patient, the time the patient left and returned to the unit,
k. Hand off assigned patient-observation rounds to another staff member before leaving the
patient treatment area (meals, breaks, emergencies)
I.
Identify, correct, or report any environmental risks while conducting observation rounds:
i.
Contraband or physical plant damage
ii.
Ensure doors that are to be locked are, in fact, locked
iii. Fire and other safety hazards in all areas
iv. Report any findings to the Charge Nurse
m. Be aware of times when your focus can be diverted:
i.
changes of shift
ii. codes
iii. crisis de-escalation
iv. patient meal times
v. patient bedtimes
vi. visiting hours
vii. patient shower times
viii. unit staff meetings

j.

II. Hand Off during the shift:
1. Charge Nurse/Nursing Supervisor/Team Leader:
a. when the staff assigned checks leaves the unit for break/emergencies, reassign patient
observation rounds.
2.

BHA:
a. Notify Charge Nurse/Nursing Supervisor/Team Leader before leaving an area and inform
them of your location.
b. Hand off the Patient Observation Rounds forms to person responsible for completing
c.

observations in your absence and advise charge nurse
Take a radio and conduct a radio check

III. Hand Off from shift to shift:
1. BHA:

a.

b.

Off-going and oncoming staff will walk/monitor the unit jointly, correlating the patient
location/behaviors with the Patient Observation Rounds form(s) to ensure continuity of
care. Deficiencies in unit environmental safety or patient accountability must be corrected
at shift change or reported to the Charge Nurse.
Both staff will initial the Patient Observation Rounds form at the time of change of shift to
indicate the completion of the handoff procedure.

2. Intake:
a. Both staff will initial the Patient Observation Rounds form at the time of change of shift to
indicate the completion of the handoff procedure.

Reference:

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•

(2008) UHS Best Practice of Patient Observation Rounds

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