Adult nursing

OSCE support materials provided on

test centres’ online learning
platforms

August 2018
 2

Contents
The test centres’ platforms.............................................................................................. 3

Digital library – eBooks ................................................................................................... 4

OSCE support materials ................................................................................................. 6

Further reading ............................................................................................................... 8

Annexes ........................................................................................................................ 10

Version 1 August 2018

 3

The test centres’ platforms

If you’re taking Part 2 of the test of competence (the OSCE), you’ll be marked against
the NMC’s current pre-registration education standards. Read the test blueprints.

Once you book your OSCE with a test centre, you’ll get access to the test centre’s own
online learning platform.

Oxford Brookes University

University of Northampton

Ulster University

On the learning platform, you’ll find support material, you will also receive access to a
digital resource library (Dawsonera and/or the Royal Marsden Manual). This document
outlines what is available as of August 2018.

The platform is also where you’ll find important updates about the OSCE. Test centres
advise you to regularly log in and check these.

As a candidate, it’s important that you familiarise yourself with the online materials. A
key document to have read and understood is the candidate information booklet.

We understand that most applicants receive training and OSCE preparation from their
employers. Employers don’t always receive access to test centres’ platforms.

We encourage trainers to regularly check the test centre websites for updates, or
directly contact test centres to stay informed.

Version 1 August 2018

 4

Digital library – eBooks

Test centres encourage you to familiarise yourself with the following eBooks, which are
available via the digital library

Dawsonera

Adam, S. K., Odell, M. and Welch, J. (2010) Rapid assessment of the acutely ill patient.
Oxford: Wiley-Blackwell.

Best, C. and NetLibrary, Inc. (2008) Nutrition: a handbook for nurses. Chichester, West
Sussex, U.K.: Wiley-Blackwell.

Booker, C. and Waugh, A. (2007) Foundations of Nursing Practice: Fundamentals of

Holistic Care. Mosby Elsevier.

Boyd, C. (2013a) Clinical skills for nurses. Chichester: John Wiley.

Boyd, C. (2013b) Medicine management skills for nurses. Chichester: Wiley-Blackwell.

Brooker, C. and Waugh, A. (2007) Foundations of nursing practice: fundamentals of
holistic care. Edinburgh: Mosby/Elsevier.

Carrier, J. (2016) Managing long term conditions and chronic illness in primary care: a
guide to good practice. 2nd ed. London: Routledge.

Chapelhow, C. (2005) Uncovering skills for practice. Cheltenham: Nelson Thornes.

Crouch, S., Chapelhow, C. and Crouch, M. (2013) Medicines management: a nursing

perspective. Abingdon: Routledge.

Dealey, C. (2012) The care of wounds: a guide for nurses. 4th ed. Oxford: Blackwell
Science.

Dougherty, L., Lister, S. E. and Royal Marsden NHS Foundation Trust (2015) The Royal
Marsden manual of clinical nursing procedures. 9th ed. Chichester: Wiley-Blackwell.
(Access shared via Dawsonera at Oxford Brookes and Ulster University)

Gatford, J. D., Phillips, N. and NetLibrary, Inc. (2016) Nursing calculations. 6th ed.
Edinburgh: Churchill Livingstone.

Goodman, B. and Clemow, R. (2010) Nursing and collaborative practice: a guide to

interprofessional and interpersonal working. 2nd ed. Exeter: Learning Matters.

Hughes, R. (2010) Rights, risk, and restraint-free care of older people: person-centred
approaches in health and social care. London: Jessica Kingsley.

Jasper, M. (2006) Professional development, reflection and decision-making. Oxford:

Blackwell.

Version 1 August 2018

 5

Jevon, P. and Ewens, B. (2012) Monitoring the critically ill patient. 3rd ed. Oxford:
Wiley-Blackwell.

Jevon, P., Ewens, B. and Humphreys, M. (2008) Nursing medical emergency patients.
Illustrated ed. Chichester: Wiley-Blackwell.

McArthur-Rouse, F. J. and Prosser, S. (2007) Assessing and managing the acutely ill
adult surgical patient. Oxford: Blackwell

McCormack, B. and McCance, T. (2010) Person-centred nursing: theory and practice.

Oxford: Wiley-Blackwell.

Merriman, C. and Westcott, L. (2010) Succeed in OSCEs and practical exams: an

essential guide for nurses. Maidenhead: Open University Press.

Payne, S., Seymour, J. and Ingleton, C. (2008) Palliative care nursing: principles and
evidence for practice. 2nd ed. Maidenhead: Open University Press.

Peate, I. (2010) Nursing care and the activities of living. 2nd ed. Chichester: Blackwell
Publishing

Royal Marsden Manual

Dougherty, L., Lister, S. E. and Royal Marsden NHS Foundation Trust (2015) The Royal
Marsden manual of clinical nursing procedures. 9th ed. Chichester: Wiley-Blackwell.
(Access shared via the online Royal Marsden Manual at the University of Northampton)

Version 1 August 2018

 6

OSCE support materials

We encourage you to familiarise yourself with these documents, which are available on
the test centres’ online learning platforms.

As new scenarios and skill stations are introduced, the test centres will make new
documentation available. This list reflects what is available as of August 2018.

More documents are available for the APIE (assessment, planning, implementation,
evaluation) stations. For clinical skill stations, we advise you to check the candidate
handbook to understand what type of clinical skills may come up in the exam. The
Royal Marsden Manual provides the basis of what is viewed as safe practice.

Examination briefing notes

These have been shared in advance to provide you with as much information as
possible for the day.

 Candidate Briefing (Annexe 1)

 Invigilator Briefing (Annexe 2)

Individual station template examples

We’ll give you pre-filled patient information ahead of the APIE stations. Here are two
example documents for two different care environments:

 Blank adult inpatient admission form/discharge letter (Annexe 3)

 Blank community discharge care letter (Annexe 4)

Here are un-filled documents individual stations. Highlighted areas are filled in for you
on the day.

 APIE: Assessment station (Annexe 5)

 APIE: Planning station (Annexe 6)
 APIE: Implementation station (Annexe 7)
 APIE: Evaluation station: Hospital setting (Annexe 8)
 APIE: Evaluation station: Community care setting (Annexe 9)
 Clinical skills: Community prescription chart (Annexe 10)

Charts and forms used in the OSCE

Test centres have shared the following charts and forms that are used in the OSCE.

On the day, some will be pre-filled. Some will be left blank for you to complete as part of
the assessment. Some will be there for reference only.

It’s important that you’re familiar with all the charts and forms so you can demonstrate
safe and patient-centred care.

Version 1 August 2018

 7

Possible charts and forms that will have pre-filled patient information are:

 Blank 24 hour fluid balance chart (Annexe 11)

o This chart is used in some of the scenarios for the implementation station
as well as some skill stations.
 Blank microbiology request form (Annexe 12)
o This form is used in some of the skill stations.
 Blank patient health questionnaire example (Annexe 13)
o This form is used in some of the scenarios for the assessment station.

Possible charts that you may need to complete as part of the assessment:

 Blank Glasgow coma neurological observation chart (Annexe 14)

o This chart is used in some of the scenarios for the assessment station.
 Blank NEWS2 chart (Annexe 15).
o This chart is used in some of the scenarios for the assessment station
 Blank temperature, pulse, respiration (TPR) chart (Annexe 16)
o This chart is used in some of the scenarios for the assessment station.

For reference only:

 Blank peak expiratory flow rate chart (Annexe 17)

o This chart is used as guidance for applicants for some of the scenarios for
the assessment station.

Version 1 August 2018

 8

Further reading
The weblinks complement the OSCE documentation support materials and provide
further guidance. Again, this list may get added to and updated as and when
appropriate.

The below list of weblinks have been recommended by test centres on their learning
platform to provide additional guidance:

Age UK
 Nursing the older person

British National Formulary

 main website/guidelines

Resuscitation Council (UK)

 Guidelines
 Videos

British Thoracic Society Guidelines

 Administration of oxygen

Department of Health and Social Care

 National dementia strategy

Essence of Care 2010

 Communication benchmarking

National electronic library of infection

 Infection control

National Outreach forum

 ‘How to Guide’ for reducing harm from deterioration

NHS Choices
 Depression self-assessment

NHS England
 Improving care for older people

NHS Improvement
 SBAR communication tool

NICE guidelines
 Venous thromboembolism
 Routine pre-operative tests for elective surgery
 Asthma

Version 1 August 2018

 9

Nursing and Midwifery Council

 Standards for pre-registration nursing education
 Standards for medicine management
 Standard for competence of registered nurses/midwives
 Test blueprints (adult nursing)
 The Code
 Guidance
 Concerns about nurses and midwives

Nursing Times
 Effective communication skills

Royal College of Nursing

 Care of older people guidance
 Privacy and dignity
 Rehabilitation and the older person
 Sharps safety

Royal College of Physicians

 NEWS2 Information
 free e-learning unit for NEWS2

Stroke Training
 Main website

World Health Organisation

 Hand washing

YouTube
 Compassion in practice – it’s in your hand video
 A new vision for nurses, midwives and care staff

Version 1 August 2018

 10

Annexes
Annexe 1: Candidate briefing

Annexe 2: Invigilator briefing

Annexe 3: Adult inpatient admission/discharge form

Annexe 4: Community discharge care letter

Annexe 5: APIE assessment station

Annexe 6: APIE planning station

Annexe 7: APIE implementation station

Annexe 8: APIE evaluation station hospital setting

Annexe 9: APIE evaluation station community care setting

Annexe 10: Clinical skills community prescription chart

Annexe 11: 24 hour fluid balance chart

Annexe 12: Microbiology request form

Annexe 13: Patient health questionnaire

Annexe 14: Glasgow coma scale chart

Annexe 15: NEWS2 Chart

Annexe 16: Peak expiratory flow rate chart

Annexe 17: Temperature, pulse, respiratory rate observation chart

Version 1 August 2018

Candidate Briefing
 You must be dressed appropriately for your area of clinical practice and so
demonstrate awareness of the importance of infection control in healthcare practice:

o Only smooth stud earrings

o No necklaces
o Only smooth rings (e.g. wedding ring)
o No watches, arm bands or bracelets
o Hair must be well above the collar, with no decorative accessories
o No nail varnish, gels or false nails
o No low-cut tops
o Suitable black shoes

 You must wear the photographic ID provided at all times while you are in the testing
area. No other ID may be worn.

 Online learning platform: Have you accessed the resources and videos? If not, do you
wish to continue? If yes, you must sign a disclaimer as you will not be able to appeal on
these grounds.

 The OSCE assessment is assessed in English and you must speak English at all times in
the test centre.

 When you have finished your OSCE assessment, talking or discussing your assessment
with other candidates could be interpreted as cheating and could result in a fail.

 The use of phones is forbidden at all times in the test centre. Use of a phone for any
reason, will be considered cheating. Put your phone on silent and place in your locker as
soon as you have received your photographic ID.

 You must be physically fit and well enough to undertake the assessment, which may
include physical activity.

 If you feel unwell or need any reasonable adjustments, advise an examiner or invigilator
immediately.

 You must remain in the testing area unless instructed to leave by the invigilator or fire
marshal.

 Your invigilator will answer general questions. All technical questions must be
addressed to an examiner.

 Practice thermometers are available for you on the tables in reception. If you need
help using them, please ask the receptionist.

Follow your codes and behave as though you are in professional practice at all times

Version 1 20180620
  Please remember that the CTC is a training centre and you may be asked if an observer
can sit in on an assessment. If you would prefer not to have an observer present, this
will not affect the result of your assessment in any way.

 Each OSCE lasts approximately 15 minutes and all assessments are recorded for
moderation purposes.

 The assessor will show you the equipment and layout of the station before the timer is
started.

 The assessor will notify you when the assessment has begun and will prompt you with
time remaining.

 Do not add anything after the timer has reached zero, it will not be included in the
marking and will be classed as cheating.

 Do not attempt to re-enter a station once you have left. It is classed as cheating and
unprofessional behaviour.

 Do not talk to other candidates between stations or during toilet breaks.

 The assessor will verbalise any relevant information before each OSCE starts.

 Use the equipment provided in each station. If you need additional equipment, or
advice on how to use equipment, please verbalise this to the examiner.

 Some assessments require you to record information on nursing documentation - you

must meet NMC guidelines at all times.

 Verbalise what you are doing and why (e.g. the area is safe, the patient’s airway is
clear).

 Talk directly to the patient (simulated patient/manikin) not the examiner. If a manikin is
being used, talk to it as if it is a real person - the examiner will answer questions as the
patient if appropriate.

 Examiners will not give you any feedback on your performance, however they may ask
you questions and provide you with relevant information during your assessment.

 If you make a mistake, verbalise what you would do in practice.

 Verbalisation of any errors or omissions during your assessment will not overturn a
critical fail element.

 In the event that any candidate demonstrates unsafe practice which may place the
candidate, simulated patient or examiner at risk, then a U score (unsafe practice) must
be awarded, and the station will be stopped.

If you have any technical questions, please ask an examiner.

For general questions, please ask an invigilator.

I confirm that I have read and understood this OSCE Candidate Briefing.

Date: __________ Signed: ____________________ Print Name: __________________

Version 1 20180620
Invigilator Briefing
1. Fire exits: All labs contain fire doors. Please stay with examiner when exiting.
2. Are you suitably dressed for clinical practice? Only smooth stud earrings (1 pair), no
necklaces, only 1 smooth ring (e.g. wedding bands). No watches or arm bands, lower arms
need to be bare. Hair must be up above the collar and off the face. Nails must be cut
short, no nail varnish and no gel/false nails. Please wear suitable shoes.
3. Have you accessed Online learning platform resources and videos? – If you have not, do you
wish to continue? If yes, you must sign a disclaimer, as you are not allowed to appeal on
these grounds.
4. If you need anything today please ask the invigilator – water, toilet breaks and rests are all
available.
5. If you feel unwell, please let any member of staff know.
6. Technical questions must be directed to the Examiners.
7. Do you have a pen, fob watch and pen torch? If not, please get one from the receptionist.
If your pen runs out we have spare pens - just ask.

Today you will undertake Part 2 of the OSCE Test of Competence

Six Stations – four Nursing Processes and two Skills

1. A = Assessment of a real person with questions and answers. Please write your name on
the top of the assessment sheet so that we can ensure all your paperwork stays
together.
2. P = Planning care. Two written aspects of nursing care and self-care. You must use todays
date on all your documentation. Complete all documentation. This is a written silent station
which is also filmed. Please write your name on the planning sheet paperwork.
3. I = Implementation. Drug administration is with a manikin and you must use todays date on
all your documentation. Complete all documentation.
4. E = Evaluation. A transfer letter about your patient – complete all documentation. This is a
written silent station which is also filmed.
5. Today you will be asked to complete two skills using a manikin.

In the Examination Room

The examiners are there in an examiner capacity and the expectation is that you will be a lone
practitioner.

At the start of each station the examiner will ask you the following questions:

 Please can you confirm that you do not know the examiner, invigilator or the
actor (if applicable to the station) outside of this examination, and they were
not involved in the preparation of this exam.
 Please can you confirm that you are fit and well to take this station.

Please can you respond to these questions with one of the following responses:
‘Yes, I can confirm this is true.’ or ‘No, that is not true.’

Before you begin each station there will be a recap summary, the following questions will be
asked:

Version 1 20180620
 Do you understand what is expected of you?
 Are you fit and well to proceed?
 Do you have any questions?
 Are you ready to start?

Please can you respond to these questions with one of the following responses:
‘Yes.’ or ‘No.’

Decontaminate hands as you would in the practice setting. Use your clinical judgement - we
have hand gel available.

Manikins. Please talk to the manikin as if it is a real person. Examiners will answer any
questions and engage in conversation as required. Please look at the manikin rather than the
examiner.

Feel stuck or panicking? You can ask the examiner if you feel stuck. The examiners will reply:
‘What would you do in practice?’

If you need help for example, to raise the bed or open anything, please ask the Examiner to do
it for you. If you have any questions or need clarification, please ask the examiner.

If you make a mistake – Please tell the examiner straight away and tell them what you would do
in practice. You can verbalise any errors or omissions in the timed station only. Verbalisation
will not overturn an issue of unsafe practice.

Follow the NMC Code and behave as though you are in professional practice at all times.

All stations will have a camera in them, which is set to continuously record. On entering the
station you will be asked to confirm your name to the camera and confirm that you do not
know the examiner.

1. All stations have a digital clock which is set with the time for that station.
2. All documentation is given to you in the station and you will be given time to read it.
3. You will be shown the layout of the station and shown the equipment. I can confirm that
this is a latex free environment and there will be no latex in any of the stations.
4. If equipment is different to what you normally use please tell the examiner, who will be
happy to show you how to use it.
5. Examiners will not prompt you as to what to do next.
6. Examiners will prompt you with the time remaining.
7. When the timer reaches zero, that part of your exam is over. There will be no extra time
unless a technical issue arose.
8. Do not add anything after the timer has reached zero, as it cannot be included and would
be classed as cheating.
9. Do not attempt to re-enter a station once you have left. This would be classed as cheating
and unprofessional behaviour.
10. You must not talk to other candidates in between stations or attempt to write on anything
as this is cheating.

If you have any questions please ask your invigilator or examiners.

Version 1 20180620
 1
Filled out on day of examination
ADDRESSOGRAPH
Adult Inpatient Admission/Discharge Form and
LABEL
Trust Core Patient Activities of Daily Living (ADL)

Initial Assessment

Ward ____________________________________

Type of admission Is the above address your permanent Yes No

residence?
Accident and Emergency Clinic
Have you been resident in the UK Yes No
General Practitioner (GP) Other for 12 months?. If NO, complete NGV1398
Notification of overseas visitors.
Date of admission:____________ Time: _________
Next of kin
Estimated date of discharge: ________________ Name ____________________________________

Consultant: ________________________________ Relationship: ______________________________

Named nurse : _____________________________ Address: _________________________________

Reason for admission: __________________ Postcode _______________

___________________________________ Telephone numbers Home ___________________

___________________________________ Work: ___________ Mobile: __________________

Does the patient agree to next of kin Yes No

Diagnosis/operation: being notified of admission and condition?

__________________________________ Notified Yes No If NO, reason:

___________________________________ Significant others

Name: ____________________________________
___________________________________
Relationship: _______________________________

Previous medical history: Address: __________________________________

__________________________________ __________________ Postcode ______________

__________________________________ Telephone numbers Home: _________________

__________________________________ Work: ____________ Mobile: ________________

___________________________________ Notified Yes No If NO, reason:

___________________________________ Name and Contact number for night time:

_________________________________________
___________________________________
VALUABLES Yes No Hospital policy
Single assessment document Yes No explained

House keys Glasses Hearing aid

Dentures Contact lens
Preferred Name: ____________________________
Property details:
Age: _______________ Status ________________
General office Home Retained by patient
NB. Refer to disclaimer on page 2.
Religion: ___________ Ethnic origin ___________
Medication Brought in Yes No
Does the patient agree to their Yes No
If YES, Retained on ward Sent home
name/information being written
on white boards in wards?
 2
Patient Orientation Checklist – Nursing Staff to Complete

All items in this checklist must be discussed with the patient on admission and on internal transfer.

Please tick
when discussed
Patient Orientation Checklist discussed with patient

Introductions made – Introduce yourself by full name to the patient

Name of ward - Advise the patient of the name of the ward that they have been
admitted to and what sort of ward it is

Name of ward –Either show the patient around the ward or advise where the
toilet/bathroom facilities/ day rooms/visitors lounge etc. are located on the ward

Call bell devices – Explain to the patient how the call bell device works and when to
use it

Drinks/snacks – Advise the patient how to get snacks/drinks in between meals

should they want them

Personal belongings – Advise the patient where to store personal belongings and
for security reasons, not to store anything of value here. Anything of value is to be
stored as per Trust policy (member of staff to advise)

Visitor information – Advise the patient of visiting times, car parking for visitors
and temporary permit provisions if appropriate.

Patient information leaflet given

Patient’s comments (if any):

Patient Safety information leaflet – NGV1467 given

Sign and PRINT your name below to confirm that you have discussed this checklist with the patient.

Signature ______________________ PRINT name ____________________________

Designation _____________ Ward ________________ Date ___________________

DISCLAIMER

I hereby indemnify the ___________________ NHS Trust against any loss or damage to

property/monies that I do not wish to be held in safe custody on my behalf by the hospital.

Signature of patient ______________________________________________________________

Name (block capitals) _____________________________________________________________

Date ____________________________
 3
On Admission

Allergies (include medicines, latex, food, State reaction experienced:

other)

1. Do you have a reaction to latex/rubber products Yes Go to question 2

No (no allergy) Go to question 3

2. What kind of reaction do you have:

Localised eczema on skin in contact with rubber only Yes (Type 4)

No (no allergy)

and/or (Type 1) (Type 4)

Hives Yes No
Wheezing Yes No
Difficulty breathing Yes No
Swelling of lips/tongue/throat Yes No
Collapse Yes No
Other (please describe): Yes No

3. Do you have a rash, itching, swelling or hives after Yes No

contact with rubber products such as household gloves
or balloons,
If YES, go back to question 2

Allergy identified, inform medical staff, anaesthetist as appropriate

No allergy Type 4 allergy Type 1 allergy

Making every Contact Count – NGH Nursing Admission Questions

Smoking

1. Does the patient smoke? Yes No

No – No further action
Yes – Offer a ‘Time for a QUIT Chat’ brief advice intervention and recommend a referral to the NHS
Stop Smoking Service.
- Complete a Time for a QUIT Chat Referral form NGV1547 or via the referral form on the ICE
System
- Combustibles - Sent home Locked away

Date of referral ______________________________ Signature ___________________________

Alcohol Harm Reduction Scoring system Score

0 1 2 3 4
Never Monthly 2-4 2-3 4+
How often do you have a drink containing or less times times times
alcohol per per per
month week week
How many units of alcohol do you drink on a 1-2 3-4 5-6 7-9 10+
typical day when you are drinking?

How often have you had 6 or more units if Never Less Monthly Weekly Daily
female, or 8 or more if male, on a single than or
occasion in the last year? monthly almost
daily
TOTAL
 4

Alcohol Harm Reduction continued

A score of 0-7 indicates lower risk drinking

A score of 8-15 indicates increasing risk drinking – Give the patient a copy of Patient
Information Healthy Lifestyles Leaflet NGV1577.

A score of 16-20+ refer to the NGH Alcohol Liaison Nurse

Date of Referral _________________________ Signature _____________________________

Social History

Do you live alone With others Who ________________________________

Do you have dependents Yes No

If yes, who is caring for them ________________________________________________________

Type of accommodation and how long at this address:

House Flat Floor e.g. 1,2,3,4,5,6 ________ Lift: Yes No Bungalow

Mobile home Other _____________________ Warden controlled accommodation

Contact number: __________________________________________

Nursing home Residential home Name and address _________________________

Access to home

What is the access to the property – specify how many steps, slope, etc________________________

How many toilets are there in the property and where are they located? _______________________

Type of heating: Central heating Electric Gas Wood/coal

Where is the bathroom located (indicate floor) __________________________________________

Where do you sleep? Upstairs Downstairs

What equipment do you have at home? Grab rails Where are these situated__________

Zimmer frame Rota stand Stair lift Hoist

Pressure relieving mattress Pressure relieving cushion

Other (please specify) ______________________________________________________________

Do you have dependent others or pets that will require support whilst you are in hospital?

Yes No Specify ____________________________________________________

PRINT name ___________________________________ Signature _________________________

Designation ____________________________________ Date _____________________________

 5

Pre admission services

Social worker name and contact number ________________________________________________

Care package Monday Tuesday Wednesday Thursday Friday Saturday Sunday

How many times

Care package includes: ______________________________________________________________

Yes No

Community/specialist nurse

Physiotherapist

Occupational therapist

Health Visitor

Psychiatric nurse

Warden

Life line/Vitalink/Other

Pet system

Keysafe

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Age concern

Voluntary

Meals on wheels
(hot/frozen)

Day Hospital

Day Centre

Interagency Community Team ________________________________________________________

Other (please specify) ______________________________________________________________

Informal care arrangements

Are there any friends/neighbours/family providing help? Yes No

Please specify ____________________________________________________________________

Are they happy to continue this – Patient Yes No Carer Yes No

Personal tasks Who does the following?

Self Others - identify Self Others - identify

Cooking Cleaning

Laundry Ironing

Hygiene needs Medication

Shopping Finances

Is a continuing health care assessment required? Yes No

If yes, contact social work department.

 6
Trust Core Patient Activities of Daily Living –
Initial Assessment
NHS Trust applies The Roper, Logan and Tierney model of nursing which is a model of care
based upon activities of daily living (ADL’s). These activities are mainly used on admission as a basis
to assess and compare how life has changed due to illness or injury resulting in admission to hospital
and to plan appropriate nursing care following assessment.

All inpatients require these assessment tools to be completed on admission to the hospital
as indicated following Activities of Daily Living Assessment.

A Trust Fall Assessment Tool – within 12 hours

B Trust Patient Handling Assessment Tool – within 12 hours

C Trust Pressure Prevention Assessment Tool – within 8 hours

D Trust Nutritional Screening Assessment Tool – within 24 hours

E Trust Pain Assessment Tool – on admission

Signature __________________________________ Time _____________ Date _____________

PRINT NAME/Stamp _______________________________________________________________

To be completed in full by admitting nurse.

Activities of Daily Living Assessments

1a Maintaining a safe environment (prompts)

a Orientation to place Yes No d History of confusion Yes No

b Orientation to time Yes No e Have you fallen recently Yes No

c Orientation to ward Yes No f Appears rational Yes No

and bed area given

Additional information: If YES to d, e, or f, complete Trust Falls Care Plan page 11

1b Is the VTE Risk Assessment complete Yes No

If Yes – commence appropriate prescribed treatment

- refer to AES core care plan NGV1459

If No - escalate to medical staff

 7
1c Dementia and carers of patients with dementia

Has the patient a diagnosis of dementia?

Yes No
 Utilise Butterfly magnet  Does the patient have signs of delirium or
 Complete Butterfly patient profile cognitive impairment?
 Give the patient/carer ‘Information for
Carers of patients with dementia’ leaflet If yes, Utilise ‘Outline Butterfly’ magnet
NGV1581
 Does the carer want to be involved in the
patient’s care whilst in hospital? Refer to
Carer’s policy
 Does the carer require further support? If yes,
contact Carer Assessment and Support Worker
(CASW)
2. Communication (prompts)

Blind Yes No Partially sighted Yes No

Glasses Yes No Contact lens Yes No

Glasses/lens with patient Yes No

Additional information :

N.B. Are there any learning disability concerns Yes No

If YES, commence Learning Disabilities Passport NGV1516

If YES, contact the Learning Disability Nurse, ext (Monday-Friday) 09.00-17.00 or on call duty nurse

Community hospitals ring ____________________________________________________________

N.B. Are there any safeguarding/mental capacity concerns Yes No

Is a Mental Capacity Assessment required? Yes No

If YES, contact Safeguarding Lead, bleep (Monday-Friday) 09.00-17.00 or on call duty nurse for further advice
and support.

Community hospitals ring ___________________________________________________________

b) Hearing:

Deaf Yes No Partially deaf Yes No

Lip reader Yes No Sign language Yes No

Hearing aid with patient Yes No Does hearing aid work? Yes No

If NO, record action taken :

(Consider use of Piticom Booklet) _____________________________________________________________

Additional information:

c) Speech and Language (prompts):

Understands English Yes No Speaks English Yes No

Translator required Yes No

First language spoken if not English ____________________________________________________________

(Consider use of Piticom booklet)

Additional information :
e.g. patient aphasic or suffers from dysphasia
 8
3. Mobility (prompts) Complete Trust Pressure Prevention Assessment Tool, page 17
Complete Patient Handling Assessment, page 14

Independently mobilises Yes No Assistance/supervision required Yes No

Identify aids used _________________________________________________________________

Additional information:

4. Eating and Drinking (prompts) Complete Trust Nutritional Screening Assessment Tool, pg 25

Able to swallow Yes No Difficulty swallowing Yes No

Wears dentures Yes No Dentures with patient Yes No

Top set Yes No Bottom set Yes No

Special diet required Yes No

If YES, identify _________________________________________________________________

Information required regarding - healthy eating Yes No

- weight management Yes No

If YES, refer to nutritional team

Referral date_________________________________ Signature _________________________

Additional information

5. Personal hygiene and dressing (prompts) Complete Trust Oral Care Assessment Tool
NGV1465

Independent Yes No Requires assistance Yes No

Additional information:

6. Elimination (prompts)
a) Urine
Do you have to go to the bathroom during the night Yes No

Do you suffer from frequency of passing urine Yes No

Do you have any concerns regarding passing urine Yes No

Do you have a long term catheter Yes No

Additional information :

All patients must have a full urinalysis taken and documented below/or attach urometer
print out. Any abnormalities detected must be reported to medical staff immediately.

Date Specific gravity Urine PH Leucocytes Nitrate Protein

Glucose Ketones Urobilinogen Bilirubin Blood erythrocytes

 9
b) Bowels (prompts)

Normal habit ______________________________________________________________________

Stoma present Yes No

Have you noticed any change in your bowel habits, i.e. Blood in stools Yes No

Diarrhoea Yes No

Constipation Yes No

Other _____________________________

Additional information : If YES to any of the above, commence

Diarrhoea Trust Care Plan NGV1106

7. Breathing

Asthma Yes No Chronic obstructive airway disease Yes No

Breathlessness Yes No Smoker Yes No

Other long term breathing problems: __________________________________________________

Identify inhalers (if used) ____________________________________________________________

Additional information:

8. Sleeping (prompts)

Usual sleeping habits _______________________________________________________________

Takes night sedation Yes No If YES, identify medication _____________________

Sleep interrupted Yes No If YES, by what, e.g. bathroom __________________

If YES, what helps ____________________________

Additional information:

9. Expressing sexuality (prompts). Be aware of privacy and dignity requirements, cultural

and religious beliefs.

Altered body image, e.g. prosthesis, hair loss, stoma Yes No

Requires further discussion Yes No If YES, who __________

Additional information:

Date of referral ______________________ Signature ___________________________________

 10

10. Death and dying

Visit required from religious/spiritual personnel Yes No

If YES, what arrangements have been made ____________________________________________

Additional information:

If appropriate:

 Has DNACPR status been considered Yes No

 Has the patient been identified as requiring end of life care Yes No

If YES, have relatives/carers been informed/consulted Yes No

 Has a chosen place of death or care been identified Yes No

If YES, where _______________________________________________________________

Does the patient hold any beliefs that required burial within 24 hours of death Yes No

Additional information:

11. Pain – Complete Pain Assessment, page 27 or if appropriate, then Trust Pain
Assessment Tool and Core Care Plan for Patients with Learning Disabilities (Adult) and
Patients who have Dementia or Cognitive Impairment NGV1545.

Do you take regular analgesia Yes No

Are they effective Yes No

Are you in pain Yes No

Is analgesia prescribed Yes No

Additional information: (note alternative methods of pain relief

12. Working and playing

How do you spend your days Work __________________ Hobbies/leisure _________________

Do you undertake any physical activity? Yes No

If YES, what are they ______________________________________________________________

Is there anything about your stay in hospital that is of concern? Yes No

If YES, what ____________________________________________________________________

Action taken _____________________________________________________________________

Name of nurse assessing:_________________ PRINT name ___________________ Date _________

 Scenario
Discharge Care Letter

Scenario

Filled out on day of the examination

Assume it is TODAY and it is xx:xx hours.

This documentation is for your use and is not marked by the examiners.

Version 1 20180620
Discharge Care Letter –filled out on day of the examination

Patient Details:
Name:
Next of Kin Details:
Hospital Number:
NHS Number:
Name, Relationship
Date of Birth:
Contact Number
Address:

Patient GP:
Name
Address
What was the main reason for admission?

Date of admission:

Primary Diagnosis

Actual and/or potential nursing care needs/problems/activities of daily living identified

during patient stay.

Nursing/Medical Interventions

Past Medical History

Medications

New Medications added this admission:

Version 1 20180620
Allergies

Social History

Discharge Summary

Name (print):
Nurse Signature:
Date: Yesterday
Date and time of transfer: Yesterday, xx:xx

Version 1 20180620
Assessing Care
Complete a Nursing Assessment of your patient.

An observation chart is provided and must be completed within the station.

(Failure to complete the chart before leaving the station will result in a fail).

Scenario

Filled out on the day of the examination

Assume it is TODAY and it is xx:xx hrs. The patient has just arrived.

This documentation is for your use and is not marked by the examiners.

Version 1 20180620
Nursing Assessment Candidate Notes – not marked

Patient Name, Hospital Number xxxxxx xxx

Patient Address xxx xxxx
Patient DOB xx/xx/xxxx

Maintaining a Safe Environment

Breathing

Communication/Pain

Controlling Temperature

Mobilising

Sleeping

Elimination

Version 1 20180620
Additional Notes

Version 1 20180620
Planning Care

Candidate Name: _____________________________________________________________

Note to Candidate:

Document to NMC standards.

The examiner will retain all documentation at the end of the station.

Scenario

Filled out on the day

Based on your Nursing Assessment of the patient, please produce a Nursing Care Plan for 2
relevant aspects of Nursing Care and Self-Care suitable for the next xx hours.

Complete all sections of the document.

Assume it is TODAY and it is xx:xx hrs.

Version 1 20180620
Patient Details: xxxxxxxxx
Name (Hospital Number) xxxxxxxxxx
Date of Birth xx/xx/xxxx
Address xxxxxxxx

1) NURSING PROBLEM/NEED/ACTIVITY OF DAILY LIVING:

AIM(S) OF CARE:

RE-EVALUATION DATE:

CARE BY NURSE(S) SELF-CARE

Name (print):
Nurse Signature:
Date:

Version 1 20180620
2) NURSING PROBLEM/NEED/ACTIVITY OF DAILY LIVING:

AIM(S) OF CARE:

RE-EVALUATION DATE:

CARE BY NURSE(S) SELF-CARE

Name (print):
Nurse Signature:
Date:

Version 1 20180620
This page is not a required element but for use in case of error.
3) NURSING PROBLEM/NEED/ACTIVITY OF DAILY LIVING:

AIM(S) OF CARE:

RE-EVALUATION DATE:

CARE BY NURSE(S) SELF-CARE

Name (print):
Nurse Signature:
Date:

Version 1 20180620
Implementing Care
Candidate Name: ____________________________________________________________________

Hernia [FEMALE]

Note to Candidate:

Document to NMC standards.

The examiner will retain all documentation at the end of the station.

Scenario

Filled out on day of examination

● Talk to your patient.

● Please verbalise what you are doing and why to the examiner.
● Read out the chart and explain what you are checking/giving/not giving and why.
● Complete all the required drug administration checks.
● Complete the documentation and use the correct codes.
● The correct codes are on the chart and on the drug trolley.
● Check and complete the last page of the chart.
● You have 15 minutes to complete this station, including the required documentation.
● Please proceed to administer and document their xx:xx hours medications, safely in
accordance with the NMC standards.

Complete all sections of the document.

Assume it is TODAY and it is xx:xx hours

Version 1 20180620
 xxxxxxxx
Name
xx/xx/xxxx
Hospital Number:
Prescription Chart for: name sex xx/xx/xxx
Date of Birth:
xx
Address

Admission Date and Time: Filled out on day of examination

Known Allergies or Sensitivities Type of Reaction

Filled out on day of examination Filled out on day of examination

Signature: Dr: A.Kumar Date:

INFORMATION FOR NURSES ADMINISTERING
Information for Prescribers:
MEDICATIONS:

USE BLOCK CAPITALS. Record time, date and sign when medication is
administered or omitted and use the following
SIGN AND DATE AND INCLUDE BLEEP codes if a medication is not administered:
NUMBER.

6. ILLEGIBLE/INCOMPLETE
SIGN AND DATE ALLERGIES BOX- IF NONE- 1. PATIENT NOT ON PRESCRIPTION, OR
WRITE "NONE KNOWN". WARD. WRONGLY PRESCRIBED
MEDICATION.

2. OMITTED FOR A
RECORD DETAILS OF ALLERGY. 7. NIL BY MOUTH
CLINICAL REASON

DIFFERENT DOSES OF THE SAME

3. MEDICINE IS NOT
MEDICATION MUST BE PRESCRIBED ON 8. NO IV ACCESS
AVAILABLE.
SEPARATE LINES.

4. PATIENT
CANCEL BY PUTTING LINE ACROSS THE 9. OTHER REASON- PLEASE
REFUSED
PRESCRIPTION AND SIGN AND DATE. DOCUMENT
MEDICATION.

INDICATE START AND FINISH DATE. 5. NAUSEA OR VOMITING.

* IF MEDICATIONS ARE NOT ADMINISTERED PLEASE DOCUMENT ON THE LAST PAGE

OF THE DRUG CHART.
Does the patient have any YES Please check the chart before administering medications.
documented Allergies? NO
Filled out on day of
WARD CONSULTANT HEIGHT
examination
Filled out on day of Filled out on day of Filled out on day of
WEIGHT
examination examination examination
YES
ANY Special Dietary Filled out on day of
NO Filled out on day of If YES please Specify
requirements? examination
examination

Version 1 20180620
 xxxxxxxx
Name
xx/xx/xxxx
Hospital Number:
Prescription Chart for: name sex xx/xx/xxx
Date of Birth:
xx
Address

Does the patient have any YES NO Filled Please check the chart before administering
documented Allergies? out on day of medications.
examination

ONCE ONLY AND STAT DOSES:

TIME Prescribers Prescribe TIME
DATE DRUG NAME DOSE ROUTE GIVEN BY
DUE signature rs bleep GIVEN
Filled out on day
of examination

PRESCRIBED OXYGEN THERAPY:

TIME
TIME
DISCON
DATE PRESCRIBERS TARGET THERAPY STARTED
FLO TINUED
AND SIGNATURE OXYGEN INSTRUCTIO DEVICE AND
W AND
TIME AND BLEEP SATURATION NS SIGNATU
SIGNAT
RE
URE
Filled out on day
of examination

PRN (AS REQUIRED MEDICATIONS):

PRESCRIBER
TIME GIVEN
DATE DRUG DOSE ROUTE INSTRUCTIONS SIGNATURE
GIVEN BY:
AND BLEEP
Filled out on day of
examination

Version 1 20180620
 Name xxxxxxxx
Hospital Number: xx/xx/xxxx
Prescription Chart for: name sex
Date of Birth: xx/xx/xxx
Address xx

Does the patient have any YES NO Filled Please check the chart before administering
documented Allergies? out on day of medications.
examination
ANTIMICROBIALS:
Date and Signature of
Nurse Administering
1.
Filled out on day of examination Medications.
DRUG
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers'
Signature and
bleep

Date and Signature of

Nurse Administering
2. DRUG Filled out on day of examination Medications.
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers''
Signature and
bleep

Date and Signature of

Nurse Administering
3. DRUG Filled out on day of examination Medications.
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers''
Signature and
bleep

Version 1 20180620
 Name xxxxxxxx
Hospital Number: xx/xx/xxxx
Prescription Chart for: name sex
Date of Birth: xx/xx/xxx
Address xx

Does the patient have any YES NO Filled Please check the chart before administering
documented Allergies? out on day of medications.
examination

REGULAR MEDICATIONS:
Date and Signature of
Nurse Administering
1.
Filled out on day of examination Medications.
DRUG
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers''
Signature and bleep

Date and Signature of

Nurse Administering
2.
Filled out on day of examination Medications.
DRUG
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers'' Signature
and bleep

Date and Signature of

Nurse Administering
3.
Filled out on day of examination Medications.
DRUG
Code for non
administration
DATE DOSE FREQUENCY ROUTE DURATION TIME Today Tomorrow

Start
date
Finish
date
Prescribers''
Signature and bleep

Version 1 20180620
 Name xxxxxxxx
Hospital Number: xx/xx/xxxx
Prescription Chart for: name sex
Date of Birth: xx/xx/xxx
Address xx

YES NO Filled
Does the patient have any Please check the chart before administering
out on day of
documented Allergies? medications.
examination

INTRAVENOUS FLUID THERAPY:

FINI
DAT VOL RATE/TI PRESC BATCH COMME GIVEN CHECKE
FLUID SHE
E UME ME RIBER NUMBER: NCED @ BY: D BY:
D@
Filled
out on
day of
examina
tion

DRUGS NOT ADMINISTERED:

NAME AND
DATE TIME DRUG REASON
SIGNATURE

The prescription chart will be completed for candidates on the day of the examination.

Version 1 20180620
Evaluating Care

Candidate Name: ____________________________________________________________________

Note to Candidate:

This document must be completed using a BLUE PEN.

At this station, you should have access to your Assessment, Planning and Implementation
documentation, if not, please ask the examiner for it.

Please Note: there are 4 pages to this document.

Document to NMC standards.

The examiner will retain all documentation at the end of the station.

Scenario

Filled out on day of examination

Complete the transfer of care letter to ensure that the receiving nurses have a full and
accurate picture of the patient’s history and needs.

Complete all sections of the document.

Assume it is TODAY and it is xx:xx hrs.

Version1 20180620
Transfer of Care Letter

Patient Details: xxxxxxxxx

Patient Name (Hospital Number) xxxxxxxxx
Date of Birth xxxxxxxxx
Patient Address xxxxxxxxx
What is the main reason for admission?

Date of admission:

Actual and/or potential nursing care needs/problems/activities of daily living identified

during patient stay.

Nursing approaches/interventions to address identified actual or potential nursing care

needs/problems/activities of daily living:

Name (print):
Nurse Signature:
Date:
Identified areas/activities of daily living where patient is able to self-care:

Version1 20180620
ALL drugs administered from admission to discharge:

ALL drugs omitted (with reasons):

Patient allergies, reactions and any risks:

Identified/potential areas for patient education:

Name (print):
Nurse Signature:
Date:
Turn over and complete page 4

Please identify actual or potential problems that may risk or complicate the patient’s
recovery:

Version1 20180620
Name (print):
Nurse Signature:
Date:

Date and time of transfer:

Version1 20180620
Evaluating Care
Community

Candidate Name: _____________________________________________________________

Note to Candidate:

This document must be completed using a BLUE PEN.

At this station, you should have access to your Assessment, Planning and Implementation
documentation, if not, please ask the examiner for it.

Please Note: there are 4 pages to this document.

Document to NMC standards.

The examiner will retain all documentation at the end of the station.

Scenario

Filled out on day of examination

Complete the referral of care letter to ensure that the receiving nurses have a full and
accurate picture of the client’s history and needs.

Complete all sections of the document.

Assume it is TODAY and it is xx:xx hours.

Version 1 20180620
Referral of Care Letter

Client Details :xxxxxxxxxxxxx

Name (NHS Number) xxxxxxxxxxxxxxx
Date of Birth xx/xx/xxxxxx
Address xxxxxxxxxxxx
What is the main reason/purpose for the referral to the Community Mental Health Team?

Date of client’s assessment

Actual and/or potential nursing care needs/problems/activities of daily living that have
been identified which led to the referral to the Community Mental Health Team.

Identify any nursing interventions that are currently provided for the client.

Name (print):
Nurse Signature:
Date:
Version 1 20180620
Identified areas/activities of daily living where client is able to self-care:

ALL drugs currently prescribed for the client during their stay in the Care Home:

Any drugs omitted or not taken as prescribed (with reasons):

Client allergies, reactions and any risks:

Identified/potential areas for client education:

Name (print):
Nurse Signature:
Date:
Turn over and complete page 4

Version 1 20180620
Please identify actual and/or potential problems that may risk or complicate the client’s
recovery:

Name (print):
Nurse Signature:
Date:

Date and time of transfer:

Version 1 20180620
SKILL STATION
Candidate Name: ________________________________________________

Please read this Insulin prescription chart carefully. You may refer to the brief during the assessment.

Scenario

Filled out on day of the examination

All the equipment you need is provided. Please administer the __________ safely using the prescription below.
It is TODAY and it is xx:xx hours.

PATIENT DETAILS DRUG DOSE SIGNATURE

Name: xxxxxxxxxxx
Address: xxxxxxxxxxxxxx Signature:
MEDICATION
Town/City: xxxxxxxxxxxxxx TODAY at xx:xx hours
Dose
Post Code: xxx xxx Date:
Date of Birth: xx/xx/xxx
Batch Number:
ALLERGIES: Prescribers Signature: Time:
Signature (GP) Today xx:xx Signature (GP) Today xx:xx
Nurses Notes:

Print Name: Signature and Date/ Time:

Version 1 20180620
24 hour Fluid Balance Chart Frequency of Measurement

Patient details PatientP

1Hourly √ 2Hourly □ 4Hourly □
Ward: Date:

Date INPUT OUTPUT

Time ORAL Running Type of IV/Central Amount of IV Central Running total INPUT Running URINE Vomit Drainage Bowels Running
Total Line Fluid Line Fluid IV/Central Line Total Total
Oral
07:00
08:00
09:00
10:00
11:00
12:
13:
14:
15:
16:30
17:30
18:
19:
20:
TOTAL
21:
22:
23:
24:
01:
02:
03:
04:
05:
06:
TOTAL
TOTAL TOTAL BALANCE +/-
INTAKE OUTPUT
CANDIDATE NAME: NEUROLOGICAL OBSERVATION CHART
PATIENT NAME: HOSPITAL NO: DATE: TIME:

TIME TIME

Spontaneous 4
Eye opening

To sound 3
Eyes closed by
(E)

To pressure 2
swelling = C
None 1
Not testable NT
Orientated 5
Verbal response

Confused 4 Endotracheal
COMA SCALE

Words 3 Tube or
(V)

Sounds 2 tracheostomy
None 1 =T
Not testable NT
Obeys commands 6
Best motor response

Localising 5
Normal flexion 4
(M)

Abnorma flexion 3
Extension 2
None 1
Not testable NT

230 40
40
1
220 39
39
2 210 38
38
200 37

Temperature °C
37
3 190 36
36
180 35
170 35
34
Blood pressure and Pulse rate

4 160 34
33
150 33
32
140 32
31
5 130 31
30
120 30
110
6
100
90
7 80
70
60
8 50
40
Pupil 30
scale Respiration
(mm) 20

Size
Right + reacts
Reaction
PUPILS - no reaction
Size c eye closed
Left
Reaction
Normal power
Mild weakness
Severe weakness
Arms

Record right (R)

LIMB MOVEMENT

Spastic flexion and left (L)

Extension separately if
No response there is a
Normal power difference
between the
Mild weakness
two sides
Legs

Severe weakness
Extension
No response
Total GCS Score
Oxygen Saturations
 NEWS key FULL NAME
0 1 2 3 DATE OF BIRTH DATE OF ADMISSION

DATE DATE
TIME TIME

3
A+B
≥25 ≥25
21–24 2 21–24
Respirations 18–20 18–20
Breaths/min 15–17 15–17
12–14 12–14
9–11 1 9–11
≤8 3 ≤8

A+B
≥96 ≥96
94–95 1 94–95
SpO2 Scale 1 92–93 2 92–93
Oxygen saturation (%) ≤91 3 ≤91

SpO2 Scale 2† ≥97 on O2 3 ≥97 on O2

Oxygen saturation (%) 95–96 on O2 2 95–96 on O2
Use Scale 2 if target
range is 88–92%,
93–94 on O2 1 93–94 on O2
eg in hypercapnic ≥93 on air ≥93 on air
respiratory failure
88–92 88–92
86–87 1 86–87
†
ONLY use Scale 2
under the direction of 84–85 2 84–85
a qualified clinician
≤83% 3 ≤83%

Air or oxygen? A=Air A=Air

O2 L/min 2 O2 L/min
Device Device

3
C
≥220 ≥220
201–219 201–219
181–200 181–200
Blood
pressure 161–180 161–180
mmHg
141–160 141–160
Score uses
systolic BP only 121–140 121–140
111–120 111–120
101–110 1 101–110
91–100 2 91–100
81–90 81–90
71–80 71–80
61–70 3 61–70
51–60 51–60
≤50 ≤50

3
C
≥131 ≥131
121–130 121–130
111–120
2 111–120
Pulse
Beats/min 101–110 101–110
91–100
1 91–100
81–90 81–90
71–80 71–80 National Early Warning Score 2 (NEWS2) © Royal College of Physicians 2017
61–70 61–70
51–60 51–60
41–50 1 41–50
31–40 31–40
≤30
3 ≤30

D
Alert Alert
Confusion Confusion
Consciousness V V
Score for NEW P 3 P
onset of confusion
(no score if chronic) U U

2
E
≥39.1° ≥39.1°
38.1–39.0° 1 38.1–39.0°
Temperature 37.1–38.0° 37.1–38.0°
°C 36.1–37.0° 36.1–37.0°
35.1–36.0° 1 35.1–36.0°
≤35.0° 3 ≤35.0°

NEWS TOTAL TOTAL

Monitoring frequency Monitoring

Escalation of care Y/N Escalation
Initials Initials

NEW_NEWS!_v4.indd 1 11/07/2017 15:14

Chart 4: Clinical response to the NEWS trigger thresholds

NEW score Frequency of monitoring Clinical response

0 Minimum 12 hourly • Continue routine NEWS monitoring

• Inform registered nurse, who must

assess the patient
Total
Minimum 4–6 hourly • Registered nurse decides whether increased
1–4
frequency of monitoring and/or escalation of
care is required

• Registered nurse to inform medical team

3 in single parameter Minimum 1 hourly caring for the patient, who will review and
decide whether escalation of care is necessary

• Registered nurse to immediately inform the

medical team caring for the patient
Total
• Registered nurse to request urgent assessment
5 or more
Minimum 1 hourly by a clinician or team with core competencies
Urgent response
in the care of acutely ill patients
threshold
• Provide clinical care in an environment with
monitoring facilities

• Registered nurse to immediately inform the

medical team caring for the patient – this
should be at least at specialist registrar level
Total • Emergency assessment by a team with critical
7 or more Continuous monitoring of care competencies, including practitioner(s)
Emergency response vital signs with advanced airway management skills
threshold • Consider transfer of care to a level 2 or 3
clinical care facility, ie higher-dependency unit
or ICU
• Clinical care in an environment with
monitoring facilities

National Early Warning Score (NEWS) 2 © Royal College of Physicians 2017

 NHS NUMBER.................................................................

OBSERVATION CHART PATIENT

SURNAME..................................................................................

PATIENT FIRST
NAME...................................................................................

Candidate Name.................................................................

PLEASE RECORD YOUR OBSERVATIONS FROM LEFT TO RIGHT

Year
Date/Month
Time

240 40ºC
BP
230
Λ 220 39ºC
•
• 210
•
• 200 38ºC
•
• 190
•
V 180 37ºC
170
160 36ºC
Pulse
150
140 35ºC
●
130
120 34ºC
110
100 33ºC
Temp
90
80
70
X
60
50
40

Respiratory
Rate
Nurse’s
initials

V1.2 | 23/04/2018
 Peak Expiratory Flow Rate Chart

Patient name

Date of birth

Candidate name -