Before we call doctor. What info should we have handy?

[Prado]

before we call doctor. what info should we have handy? so doctor wont yell at us

pls share.

1. vital signs/ 02 sat

2. ?

3. ?

4. ?

5. ?

6. ?

[Lunah, MSN, RN]

Moved to the general nursing forum (vs. the distance learning forum) to encourage responses.

[gentlegiver, ASN, LPN, RN]

Depends on what your calling for.

Lab reports -->past labs

FSBS --> current BS & any steps taken

Falls --> VS, Neuros, Assessment, Fall HX, any blood thinners Pt may be on, c/o pain, ROM, any obvious deformities

Pain Meds --> pain level, fall HX (if applicable), location & type of pain

I find it easier to have the chart with me in case Doc wants additional information.

Tranq's --> behavior HX, current meds

[mammac5]

Full SBAR

S: Situation - who you are, who the pt is, what the patient is in the hospital for, what the problem is right now, your assessment findings, what you're concerned about.

B: Background - Vital signs, especially trends you're concerned about; mental status, glucose, skin, O2, current IV fluid and rate, urine output, code status, any abnormal labs...

A: Assessment - this is what you think the problem might be OR state that you're not sure what the problem is, but you realize something is wrong.

R: Recommendation - what do you want the provider to DO about it? "I would like you to..." come in and see the patient now, transfer pt to ICU, order CXR or other tests, change IV fluid/rate, put the pt on telemetry, talk to the family about change in code status, etc.

Then, read back any verbal orders he/she gives to make sure you got it right. Document, document, document everything you said to the provider - especially if he or she does NOT follow your recommendations for care of the patient!

[loriangel14, RN]

Perfect mammac5.We have SBAR guidelines posters at work on the wall for a reminder.

[gentlegiver, ASN, LPN, RN]

I never heard of SBAR, but I plan on implementing it at work (for myself if no-one else wants to do it)! Thank you, see my day is complete, I learned something new.

[mammac5]

JC was really pushing SBAR a few years ago...I've been out of the hospital for the past year, but I'm assuming this is still a focus for safe communication. This is valuable when calling the provider, but also a great format to follow for shift report between nurses. Bonus: It eliminates the "opportunity" for nurses to gossip or complain about the pt or family members -- just the facts, ma'am!

http://www.saferhealthcare.com/sbarsamples.pdf

[Prado]

Full SBAR

S: Situation - who you are, who the pt is, what the patient is in the hospital for, what the problem is right now, your assessment findings, what you're concerned about.

B: Background - Vital signs, especially trends you're concerned about; mental status, glucose, skin, O2, current IV fluid and rate, urine output, code status, any abnormal labs...

A: Assessment - this is what you think the problem might be OR state that you're not sure what the problem is, but you realize something is wrong.

R: Recommendation - what do you want the provider to DO about it? "I would like you to..." come in and see the patient now, transfer pt to ICU, order CXR or other tests, change IV fluid/rate, put the pt on telemetry, talk to the family about change in code status, etc.

Then, read back any verbal orders he/she gives to make sure you got it right. Document, document, document everything you said to the provider - especially if he or she does NOT follow your recommendations for care of the patient!

thanks friend,,,now i learned something while sitting at home....i will make copy of what u said,,and will keep in my pocket all the time....when ever i start working i will use ur notes...thanks again i l learnd something new

[Finallydidit]

any known drug allergies....

[gentlegiver, ASN, LPN, RN]

I work LTC so we don't really get the latest methods for calls, but I can see this as a good guideline for charting too.

[LovingNurse, BSN, RN]

As prev mentioned - SBAR is the way to go. I also have the chart on hand and computer open to that patient's info - ready for any questions that come my way ... Plus think ahead for what else you might possibly need the rest of your shift or their stay ( Anticipate the need for any prn meds? etc. ) Also, if lab values or VS are teetering on the verge of intervention - it's nice to ask if the doctor would like to give you parameters for when to give, hold, notify MD, etc. etc.,

Take your time to get your ducks in a row and jot down what you want to cover so you don't forget to ask or address.

[healthstar, BSN, RN]

In school we have learned to use the SBAR ( situation, background, Assessment for sure and if possible RECOMENDATIONS) before calling the MD. If you don't do this ahead of time you are going to be clueless on the phone with MD and the doc is likely to hang up.