Giving report about a patient over the phone to a doctor

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Specializes in (palliative care/oncology unit).

I'm certain I read a thread about this over the holidays: Giving report about a patient over the phone to a doctor. I don't know how old the thread was and can't find it again. It mentionned the details that should be transmitted to the doctor and it had a name, an acronym. If this rings a bell for anyone I would like to read it again. I have searched for it and have not been successful but I know its here somewhere.. :(

Hope this rings a bell. Thanks. :)

N_T_L

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Specializes in Gerontological, cardiac, med-surg, peds.

I believe this is the thread :)

https://allnurses.com/forums/f224/new-nurse-scared-talk-doctors-119029.html?highlight=Doctor+report+phone

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Specializes in (palliative care/oncology unit).

Thanks VickyRN!

It wasn't the exact same post but it gave me the acronym: SBAR. I was then able to find the thread again, it was tips for first year nursing..

Maybe the SBAR is of interest to others again so I repost it here from the original threads:

>>>>>>>>>

There is a well studied "cheat" sheet call the "SBAR" - follows is short version

S=situation - your name, pt name & room #, problem calling about

B=background - date of adm, adm. dx. pertinent medical hx, brief synopsis of the tx to date

A=assessment- most recent VS, O2, pulse ox, changes in assessment

R= recommendation - if the dr isn't ordering what you think the pt needs let him know, our DR.'s tell us they want to know our recommendations even if they don't always choose to follow them (tests you think need done - xray, ABG ---meds needed ----higher level of care --- dr needs to see patient, etc)

>>>>>>>>>

We recently implemented the SBAR tool at our hospital in an effort to help new nurses, or students in making sometimes dreaded phone calls to cranky physicians. If it helps, great .

I have heard that it comes from other hospitals in the US, and some of you may be familiar with it. Our new grads (and some "old" ones) have found it helpful to organize the info you want to present.

This part is the actual worksheet:

SBAR report to physician about a critical situation

S Situation

I am calling about .

The patient's code status is

The problem I am calling about is ____________________________.

I am afraid the patient is going to arrest.

I have just assessed the patient personally:

Vital signs are: Blood pressure _____/_____, Pulse ______, Respiration_____ and temperature ______

I am concerned about the:

Blood pressure because it is over 200 or less than 100 or 30 mmHg below usual

Pulse because it is over 140 or less than 50

Respiration because it is less than 5 or over 40.

Temperature because it is less than 96 or over 104.

B Background

The patient's mental status is:

Alert and oriented to person place and time.

Confused and cooperative or non-cooperative

Agitated or combative

Lethargic but conversant and able to swallow

Stuporous and not talking clearly and possibly not able to swallow

Comatose. Eyes closed. Not responding to stimulation.

The skin is:

Warm and dry

Pale

Mottled

Diaphoretic

Extremities are cold

Extremities are warm

The patient is not or is on oxygen.

The patient has been on ________ (l/min) or (%) oxygen for ______ minutes (hours)

The oximeter is reading _______%

The oximeter does not detect a good pulse and is giving erratic readings.

A Assessment

This is what I think the problem is:

The problem seems to be cardiac infection neurologic respiratory _____

I am not sure what the problem is but the patient is deteriorating.

The patient seems to be unstable and may get worse, we need to do something.

R Recommendation

I suggest or request that you .

transfer the patient to critical care

come to see the patient at this time.

Talk to the patient or family about code status.

Ask the on-call family practice resident to see the patient now.

Ask for a consultant to see the patient now.

Are any tests needed:

Do you need any tests like CXR, ABG, EKG, CBC, or BMP?

Others?

If a change in treatment is ordered then ask:

How often do you want vital signs?

How long to you expect this problem will last?

If the patient does not get better when would you want us to call again?

Guidelines for Communicating with Physicians Using the SBAR Process

1. Use the following modalities according to physician preference, if known. Wait no

longer than five minutes between attempts.

Direct page (if known)

Physician's Call Service

During weekdays, the physician's office directly

On weekends and after hours during the week, physician's home phone

Cell phone

Before assuming that the physician you are attempting to reach is not responding,

utilize all modalities. For emergent situations, use appropriate resident service as

needed to ensure safe patient care.

2. Prior to calling the physician, follow these steps:

* Have I seen and assessed the patient myself before calling?

* Has the situation been discussed with resource nurse or preceptor?

* Review the chart for appropriate physician to call.

* Know the admitting diagnosis and date of admission.

* Have I read the most recent MD progress notes and notes from the nurse who

worked the shift ahead of me?

* Have available the following when speaking with the physician:

* Patient's chart

* List of current medications, allergies, IV fluids, and labs

* Most recent vital signs

* Reporting lab results: provide the date and time test was done and results of

previous tests for comparison

* Code status

3. When calling the physician, follow the SBAR process:

(S) Situation: What is the situation you are calling about?

* Identify self, unit, patient, room number.

* Briefly state the problem, what is it, when it happened or started, and how severe.

(B) Background: Pertinent background information related to the situation could

include the following:

* The admitting diagnosis and date of admission

* List of current medications, allergies, IV fluids, and labs

* Most recent vital signs

* Lab results: provide the date and time test was done and results of previous tests

for comparison

* Other clinical information

* Code status

(A) Assessment: What is the nurse's assessment of the situation?

® Recommendation: What is the nurse's recommendation or what does he/she

want?

Examples:

* Notification that patient has been admitted

* Patient needs to be seen now

* Order change

4. Document the change in the patient's condition and physician notification.

Link on Google.

http://www.ihi.org/.../PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingM odel.htm

N_T_L

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http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

link wasn't full, just put in the correct one for anyone interested after I found it

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Specializes in Gerontological, cardiac, med-surg, peds.

I have attached an excellent guideline which is very useful in giving report: Situation Background Assessment Recommendation (SBAR). :specs:

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Wow!!! I had not seen that before and it is sure to be of future use to me!

I once saw a nurse taking report in sort of a head to toe assessment (not sure if that was clear). Has anyone seen this, and be able to explain it like the above? It was in an ICU. I sure would appreciate it!

Thanks,

WG

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