Shift Report

>30yrsRN · Oct 16, 2009

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

CapeCodMermaid, RN · Oct 16, 2009

That I can do. But by regulation, the shift report has to be in a bound book. I don't want to make the nurses write in the green book and then on another form. I was hoping someone could give me a source of a bound shift report book. Thanks for trying.

>30yrsRN · Oct 17, 2009

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 $

CapeCodMermaid, RN · Oct 19, 2009

In Massachusetts, the shift report book, most commonly called the 'green book' must, by regulation, be written in every shift and must be a bound book much like the narcotic log book. I don't know where you practice, but in this state, a loose leaf binder with reports in it would garner a citation.

>30yrsRN · Oct 20, 2009

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 $.