Nurse in Charge Report – Outpatients – Ophthalmology

If you would like to revisit your report at a later stage, please click the “Save” button at the bottom of the page and enter your email address before leaving the browser window.

Nurse or Practioner in charge*
First Last
Hospital*
Trust
Speciality*
Sub specialty*
- Glaucoma
- Medical Retina
- Cataract
- Pre-Assessment
- Post-Operative
- Plastics
- Cataract surgery
- Intravitreal Injections
- Laser clinics
- Hydroxychloroquine clinics
Days worked*
- Sat
- Sun
- Mon
- Tues
- Wed
- Thu
- Fri
Sat date
DD slash MM slash YYYY
Sun date
DD slash MM slash YYYY
Mon date
DD slash MM slash YYYY
Tues date
DD slash MM slash YYYY
Wed date
DD slash MM slash YYYY
Thu date
DD slash MM slash YYYY
Fri date
DD slash MM slash YYYY
Confirmation of staffing on each shift

In order for you and the team to be paid correctly and on time please ensure full names as per the staff report and start and finish times are completed.

Staff details

Name	Role/Allocation	Room Number	Sub specialty	Day(s) Worked	Actions
					Edit Delete
There are no Staff Members.

Maximum number of staff members reached.

eg. Jane Doe RGN Procedure Room 1 Sat

Team start time - Sat*

: Hours

Minutes
Team end time - Sat*

: Hours

Minutes
Did you finish on time - Sat
- Yes
- No
If No, please state the reason why
Team start time - Sun*

: Hours

Minutes
Team end time - Sun*

: Hours

Minutes
Did you finish on time - Sun
- Yes
- No
If No, please state the reason why
Team start time - Mon*

: Hours

Minutes
Team end time - Mon*

: Hours

Minutes
Did you finish on time - Mon
- Yes
- No
If No, please state the reason why
Team start time - Tues*

: Hours

Minutes
Team end time - Tues*

: Hours

Minutes
Did you finish on time - Tues
- Yes
- No
If No, please state the reason why
Team start time - Wed*

: Hours

Minutes
Team end time - Wed*

: Hours

Minutes
Did you finish on time - Wed
- Yes
- No
If No, please state the reason why
Team start time - Thu*

: Hours

Minutes
Team end time - Thu*

: Hours

Minutes
Did you finish on time - Thu
- Yes
- No
If No, please state the reason why
Team start time - Fri*

: Hours

Minutes
Team end time - Fri*

: Hours

Minutes
Did you finish on time - Fri
- Yes
- No
If No, please state the reason why
Did everyone turn up to the huddle - Sat
- Yes
- No
Name and reason why staff did not attend - Sat
Did everyone turn up to the huddle - Sun
- Yes
- No
Name and reason why staff did not attend - Sun
Did everyone turn up to the huddle - Mon
- Yes
- No
Name and reason why staff did not attend - Mon
Did everyone turn up to the huddle - Tues
- Yes
- No
Name and reason why staff did not attend - Tues
Did everyone turn up to the huddle - Wed
- Yes
- No
Name and reason why staff did not attend - Wed
Did everyone turn up to the huddle - Thu
- Yes
- No
Name and reason why staff did not attend - Thu
Did everyone turn up to the huddle - Fri
- Yes
- No
Name and reason why staff did not attend - Fri
You are responsible for ensuring information in this report is accurate as this a legal record. If are happy with above content please confirm.
Yes
Does your signature sheet match the staff listed on this report?
Yes
18 Week Support Signature Sheet complete and copy given to Trust link nurse?*
- Yes
- No
For all days worked
Please state reason why*
Patient Activity - confirmation of numbers for each session

Please confirm the total number of patients who are seen, those who are cancelled, and who did not attend. We are relying on your accuracy so that our financial information and feedback to the Trust is robust. For all patients treated, please ensure the numbers correspond with the patient clinical outcomes you return to 18 Week Support
Clinic - Saturday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Saturday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Saturday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Saturday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Sunday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Sunday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Sunday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Sunday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Monday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Monday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Monday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Monday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Tuesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Tuesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Tuesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Tuesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Wednesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Wednesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Wednesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Wednesday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Thursday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Thursday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Thursday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Thursday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic - Friday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Glaucoma - Friday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. Follow Ups Seen Virtual
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Medical Retina - Friday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled
Clinic Pre Assessment - Friday
Total No. of patients booked
No. New Patients Seen
No. Follow Ups Seen
No. patients DNA
No. patients left before treatment
Total No. patients seen
Total No. patients with procedure
No. patients cancelled

Cancellations

Date	Patient ID	Clinical or Non Clinical	Who made the decision to cancel?	Actions
				Edit Delete
There are no Patients.

Maximum number of patients reached.

Please accurately record reasons for patients being cancelled. If patients are cancelled for clinical reasons, this should be captured on the patient cancellation outcome form which must be signed by the relevant doctor.

Patient activity breakdown

This entire section should be completed with the number of performed procedures for each room. Please do not combine the numbers as 18WS need to report the daily activity
Ophthalmology Specific Data - Saturday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Sunday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Monday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Tuesday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Wednesday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Thursday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Ophthalmology Specific Data - Friday
New OCTs
FU OCTs
Lasers
Injections
Minor Ops
Visual Fields
FFA
Auto Flourescence
Pre-Assessment
Pentacam
Colours
Phasing
Safety-Clinical Induction

It is the responsibility of the Nurse in Charge to ensure that all 18 Week Support staff are orientated to the clinical environment and are clear on the clinical pathways for the service.
Pre-list briefing and staff allocation undertaken
- Yes
- No
For all days worked
If No, please state the reason why
Patient Journey and Referral pathway demonstrated to staff
- Yes
- No
For all days worked
If No, please state the reason why
Any incidents or near misses to report?
- Yes
- No

Incidents/Near Misses

Was this a clinical or non clinical incident	Datix Incident Number	Confirm that Trust Datix has been completed	Confirm that 18WS Datix has been completed	Actions
				Edit Delete
There are no Items.

Maximum number of items reached.

This needs to be filled in if there have been any Adverse Incidents/ complications/Serious Incidents/Never Events. All incidents must be reported onto the 18WS Datix system

Patient Complaints or Potential Complaints

Patient ID	Briefly describe incident type	Actions taken to resolve complaint	Actions
			Edit Delete
There are no Complaints.

Maximum number of complaints reached.

Anything you think may need to be followed up with the Trust

Have the patient satisfaction surveys been collected and posted from your site?
Sat
- Yes
- No
How many forms were collected? - Sat
If No, please state the reason why
Sun
- Yes
- No
How many forms were collected? - Sun
If No, please state the reason why
Mon
- Yes
- No
How many forms were collected? - Mon
If No, please state the reason why
Tues
- Yes
- No
How many forms were collected? - Tues
If No, please state the reason why
Wed
- Yes
- No
How many forms were collected? - Wed
If No, please state the reason why
Thu
- Yes
- No
How many forms were collected? - Thu
If No, please state the reason why
Fri
- Yes
- No
How many forms were collected? - Fri
If No, please state the reason why
Patients of Concern

Ophthalmology

Date	Consultant Name	Surgery/Procedures	Type of Concern	Urgent	Comments	Actions
						Edit Delete
There are no Patients.

Maximum number of patients reached.

Have the Patient of Concern Forms been completed and submitted? If there are no patients of concern, please state reason.
- Yes
- No
If No, please state reason why
Quality Assurance - Clinical Administration
Breaking bad news-patients informed regarding potential malignancy
- Yes
- No
For all days worked
If No, please state reason why
Any new cancers found?
- Yes
- No

Patient details

Patient ID	Was the patient informed?	If no, please state the reason why	Next steps	Actions
				Edit Delete
There are no patients.

Maximum number of patients reached.

All referrals, follow up tests , MDT paperwork completed.
- Yes
- No
Please ensure that you have used the correct Trust proformas to organise anything required for ongoing care ,so as to avoid delays * For all days worked
If No, please state reason why
All specimens are correctly labeled checked with the Trust link nurse and processed.
- Yes
- No
All specimens need to be checked prior to the patient leave the clinical area. Specimens should be labeled accordingly, documented correctly in the medical records and specimen request form.
If No, please state reason why
Patient outcomes sheet completed and agreed by doctor and coordinator
- Yes
- No
Within each speciality for every pateint seen we require a clinical outcome which provides an audit trail of our interaction with patient i.e procedure/test/investigations etc.
If No, please state reason why
Quality Assurance - Trust environment
Have you restocked all clinical areas?
- Yes
- No
If No, please state reason why
Have you cleaned all clinical areas?
- Yes
- No
If No, please state reason why
Have you checked all clinical equipment?
- Yes
- No
If No, please state reason why
Were there any issues with the equipment prior to the NIC leaving the unit? If yes, please report as incident.
- Yes
- No
If yes please explain?
How many Resus Trolleys are on site? - Sat
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Sun
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Mon
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Tues
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Wed
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Thu
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
How many Resus Trolleys are on site? - Fri
Location
- Ward
- OPD
- Recovery
- Other
Was the emergency equipment (Resuscitation Trolley) checked prior to the shift?
- Yes
- No
Was the emergency alerting system checked?
- Yes
- No
Was the check documented?
- Yes
- No
By whom
- Trust staff
- 18WS staff
- NIC
- Not applicable
Name
Name
Name
If No
Action taken
Other
Is the Trust link nurse happy with all the above checks?
- Yes
- No
18 Week Support Operational Issues

Issues

What was the issue/situation?	What was the impact on service?	What was the outcome?	Was the 18WS manager informed on the day?	Actions
				Edit Delete
There are no Issues.

Maximum number of issues reached.

Trust Operational Issues

Issues

What was the issue/situation?	What was the impact on service?	What was the outcome?	Was the Trust Link nurse informed on the day?	Actions
				Edit Delete
There are no Issues.

Maximum number of issues reached.

Staff issues with accommodation and travel

What was the issue/situation?	What was the outcome?	Actions
		Edit Delete
There are no Issues.

Maximum number of issues reached.

Any other comments?
Signature*
Date Completed*
DD slash MM slash YYYY
Email*

Save

Nurse in Charge Report - Outpatients - Ophthalmology

Confirmation of staffing on each shift

Patient Activity - confirmation of numbers for each session

Clinic - Saturday

Clinic Glaucoma - Saturday

Clinic Medical Retina - Saturday

Clinic Pre Assessment - Saturday

Clinic - Sunday

Clinic Glaucoma - Sunday

Clinic Medical Retina - Sunday

Clinic Pre Assessment - Sunday

Clinic - Monday

Clinic Glaucoma - Monday

Clinic Medical Retina - Monday

Clinic Pre Assessment - Monday

Clinic - Tuesday

Clinic Glaucoma - Tuesday

Clinic Medical Retina - Tuesday

Clinic Pre Assessment - Tuesday

Clinic - Wednesday

Clinic Glaucoma - Wednesday

Clinic Medical Retina - Wednesday

Clinic Pre Assessment - Wednesday

Clinic - Thursday

Clinic Glaucoma - Thursday

Clinic Medical Retina - Thursday

Clinic Pre Assessment - Thursday

Clinic - Friday

Clinic Glaucoma - Friday

Clinic Medical Retina - Friday

Clinic Pre Assessment - Friday

Patient activity breakdown

Ophthalmology Specific Data - Saturday

Ophthalmology Specific Data - Sunday

Ophthalmology Specific Data - Monday

Ophthalmology Specific Data - Tuesday

Ophthalmology Specific Data - Wednesday

Ophthalmology Specific Data - Thursday

Ophthalmology Specific Data - Friday

Safety-Clinical Induction

Have the patient satisfaction surveys been collected and posted from your site?

Patients of Concern

Quality Assurance - Clinical Administration

Quality Assurance - Trust environment

18 Week Support Operational Issues

Trust Operational Issues

18 Week Support

London

Birmingham

Follow us