Clinic LVN or TTA RN to do SOAPIE for after hours walk in?

[Spongey]

I/P walks into clinic after hours on a Friday night-no RN or MD present- just the LVN. Would the LVN; A: Complete a first responder form to gather information prior to calling MD to report anormal findings (example: fever and HTN with painful cough) and for further orders or B: Complete a SOAP note prior to calling MD or C: Do both? A little feedback from clinic LVNs and TTA RNs who work in the setting would be nice:-). Keep in mind what the scope of practice for an LVN is vs. an RN in a prison setting.

[evelynkarirn, BSN, MSN, RN]

I would expect the LVN to do the first responder note before moving to the next step. Exceptions would be rapid exsanguination, hypertensive crisis, possible CVA, acute change in mental status, or the like (call the ROVER ASAP). In any event, the LVN should be able to clearly articulate all steps they have taken, the order of the actions, the times of the actions, etc. This covers them, helps the MD/RN to take next steps based on what has already occurred so there is an easy transition of care to the TTA RN/MD. :redlight:

Hope this helps.