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. ?

[CoffeeRTC, BSN, RN]

The SBAR method and if you are in LTC, know what the resident/ family wishes are..treat at facility or send out etc.

[caliotter3]

I write down what I am going to say so that I don't leave anything out or get confused. As I go down the list, I write a check to tell myself I covered that.

[talaxandra]

I always open with "are you familiar with..." which really saves time if they've seen the patient before or have had handover from the unit.

It drives me mad when I overhear nurses ringing for IV orders/Warfarin or heparin orders/insulin/analgesics/fluid review without having the relevant information to hand. As others have said, think before you call about the kind of infomration the resident will need to make their decision or to prioritise their review.

For example: why is the patient having fluids? What and when were their most recent labs, and are they improving/declining/stable?

Why are they being anticoagulated? What's the target range?

What's their current blood glucose? How has it been? What's their usual regime? Have there been any unusual interventions or activities that might affect their glycemic management (infection, fasting, poor intake)?

What kind of pain is it? Where is it? Is it new or different? Are their vitals stable? What other interventions have been tried? Were they effective? What medical and pharmacological history is relevant (any hepatic or renal failure that might affect dosing, any cardiorespiratory impairment that might urge caution, high falls risk that indicates increasing surveillance, any history or narcotic tolerance)?

Why is a review indicated? What have they had in and out? How are their vitals? Are there clinical indicators of overload (raised JVP, increased O2 demand, bounding pulse, tachycardia or hypertension, oedema, a wet-sounding chest) or dehydration (dry mucous membranes, hypotension, weak tachycardia, thirst, poor tissue turgour, concentrated urine)?

And have a clear idea of what you want the resident to do - review the patient, urgently review the patient, give you a phone order, just be aware of a change, contact a consultant, give you a phone order and for what...

[jmolinaRN]

Wow, SBAR! Thanks for the info guys. I didn't really think there was a format to follow.

[Sarah010101]

oh wow SBAR.. this is awesome.. now i will not scramble to figure out what i need when calling :)