Shift Report

Do you know Mircosoft Word or someone that does
you can make one it very easy Examples

Name Pt,age, last four SS,RM #
Physician Name
DX
HX
Allergies, Risk like Aspirations,Fall Precautions,
Isolations
Activity
Needs I/O, FSG , BID QID etc a box for each one, NIH,ETOH WD
Girth,SCD,TEDS leg or Thigh,Kpad Traction
Wound Vac , Chest Tube, Drainages
Dressing Changes
Wound name and decribe
Air mattress, Cane,walker
O2 Dependent
VS and O2 SATS Pain level and Management
Glassess,hearing aides Left,Right
contact lens or implants,legally Blind
then each system
Oriented x4
Disoriented to Place,time or forgetful
then each system
Plan of care
Labs,Test and procedure done and pending
any preparations needed and abnormal results
Example CT scan of Chest PE + on Heparin Gtt___
IV fliuds ABTX etc..
It kind like a old Nursing Kardex

Telemetry and box # Edema,pulses Etc,
I even seen human body drawn on this for Post CABG Patients
so the writer could draw incisions marks and CT locations

well make a bound booklet any business outlet store would help you design it into a booklet with spirals or bound,They do this all the time for Presentations booklet for speakers to hand out to the Attendees.Then the Presents Highlights
on power point. It could be more cost effective if you design it. Also with the name of the hospital and area on the cover how are you giving report now?
This is not required to be in a booklet by Joint Commission. They want RN to RN verbal hand off Reports; they do not mind if you use this with these reports sheets have puncture holes to fit a notebook then place them in it. They did not ask us to save them. Why would you save them anyway? This could all be on a PC template instead this would be better since it would not store in a Book that could get lost or misplaced or fall into the publics hands... Like a Attorney.
I would ask Risk Management and Information Manegement about HIPPA Laws before you start storing a Patients Medical data record on you nursing units or drawers.There was a case recently where some Physician were keeping all Patients they treated on Warfarin,LAB ACT Records in their office files in a Veterans Hospital this was not legal and Against HIPPA
I also would refer to Medical Records Department for HIPPA documentation saved and laws that have to be met.
These papers need to go into a file 13 HIPPA Trash and are disguarded properly to insure HIPPA. This Trash bin has a lock on it and can only be removed by Designated Personnel to insure HIPPA laws are maintian. Just a thought $

We do not keep them permanently shift reports in the state I practice in go in file 13 trash that is a locked secure bin and are legally destroyed. That is interesting that your state does this. How many years are you require to keep the these bound books?
Also to answer your first question I would check with other hospitals in your State to see what bound book they use. Try the Regional Section on this Blog, I bet you will have a great response.Oh a Business center can bound the these report sheets to be bound book also but I do not know about $.