Nursing Supervision Form
Document observations, compliance, and feedback during nursing staff supervision.
Nurse's Full Name
*
First Name
Last Name
Supervisor's Full Name
*
First Name
Last Name
Date and Time of Supervision
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Shift
*
Please Select
Morning
Afternoon
Night
Other
Patient Assignment/Unit
*
Supervision Checklist
*
Rows
Compliant
Non-Compliant
Not Applicable
Hand Hygiene
1
2
3
Medication Administration
4
5
6
Documentation Accuracy
7
8
9
Patient Identification
10
11
12
Use of Personal Protective Equipment (PPE)
13
14
15
Patient Interaction and Communication
16
17
18
Safety Protocols
19
20
21
Additional Observations
Areas Requiring Improvement
Immediate Actions Taken (if any)
Supervisor's Overall Comments and Recommendations
*
Supervisor's Signature
*
Submit Supervision Report
Submit Supervision Report
Should be Empty: