Room Vacate Report- Nursing

Empowering Excellence through Information and Choice

Name of Discharge Nurse *

First

Last

Date / Time

Date

Time

URN *

Room Number *

Nursing staff are to check and report on the following items IMMEDIATELY before the patient discharges. *

	Yes- present	No- missing	Logged out	Not applicable
Remote TV	Yes- presentRemote TV Yes- present	No- missingRemote TV No- missing	Logged outRemote TV Logged out	Not applicableRemote TV Not applicable
Remote Blind	Yes- presentRemote Blind Yes- present	No- missingRemote Blind No- missing	Logged outRemote Blind Logged out	Not applicableRemote Blind Not applicable
Swipe card	Yes- presentSwipe card Yes- present	No- missingSwipe card No- missing	Logged outSwipe card Logged out	Not applicableSwipe card Not applicable
Duress alarm	Yes- presentDuress alarm Yes- present	No- missingDuress alarm No- missing	Logged outDuress alarm Logged out	Not applicableDuress alarm Not applicable
Logged out of Netflix	Yes- presentLogged out of Netflix Yes- present	No- missingLogged out of Netflix No- missing	Logged outLogged out of Netflix Logged out	Not applicableLogged out of Netflix Not applicable
Logged out of all other streaming devices	Yes- presentLogged out of all other streaming devices Yes- present	No- missingLogged out of all other streaming devices No- missing	Logged outLogged out of all other streaming devices Logged out	Not applicableLogged out of all other streaming devices Not applicable

Items are missing & require billing. *

Patient has discharged *

Patient has transferred rooms

Number of new room