What infos should I have in hand when calling a patient's doctor? just curious..

Published

Just curious, what kind of information? for example do i need to recite all the patients meds? all laboratory tests recent and old? what kind of assessment should i include like do i say i find the patient SOB- do i still include that? or could you give me examples of assessment you would normally tell? I know the questions I'm asking may seem really trivial if not stupid, but i just wanted to know. Better ask than seem like a know it all. Thank you colleagues, you're my best friends and I appreciate all the information you could give me and rest assured I will put them in good use.

Up Vote Up Vote ×

Are you a student or new nurse?

First off...when you call the doc, make sure you are ready and have all the info with you.

I start off by asking the doc if they are familiar with this pt or resident (yes makes things so easy!)

Give a description of the problem. Have the vital signs ready, current med list and allergies, current labs if applicable.

Have in mind what you want from the doc.

If it is SOB for an example..get your vitals, listen to the lungs, get a pulse ox. If they are on Nebs or other breathing meds let the doc know..Know the dx.

Be prepared as much as you can, but don't be afraid to let the doc know you don't have that info at your finger tips but will get it asap or in a few seconds.

Practice doing this with another nurse first.

Up Vote Up Vote ×
Specializes in Hospice.

It all depends on why you're calling the doc.

Minimum, be able to identify the pt and if the doc you're calling isn't familiar with the pt (ie on call but not PCP), be ready to give a very brief rundown of admission dx and relevant problem list. State the issue (ie the pt is SOB)and give your focused assessment, including vital signs. Have the chart and MARs in front of you to answer any questions the doc might have.

In short: who is the pt, what's the problem, what did you assess, what did you do, what do you want from the doc?

Leave out irrelevancies ... if you're calling because pt is sob, then doc doesn't need to know about diet (unless pt is allergic and may be having a reaction), skin lesions or bowel status.

As for labs, you can volunteer info (ie an elevated BNP) if you're sure it's relevant, but the doc will usually ask for the info s/he needs. The key is to set yourself up to be able to locate the info quickly ... chart open or up on the computer, MARs in front of you.

At least that's how I do it.

Up Vote Up Vote ×
Specializes in Hospice.

Ahh ... sniped by michelle126. GMTA!

Up Vote Up Vote ×
Specializes in Critical Care.

I try to use SBAR format when I call

Situation

Backround (sort and sweet, maybe what they had done

Assesment (again short, what's wrong right now)

Recomendation (what do you want me to do, or here's what I want to do when you get more experience)

Also 1st make sure you have the right resident and they are familiar w/ the pt,and don't draw a blank and forget the patient's name (both things I frequently do wrong)

Hope this helps

Up Vote Up Vote ×
Specializes in LTC, Memory loss, PDN.

First question to answer, as michelle 126 posted, is what is the purpose of the call, what do you want from the doc.

Up Vote Up Vote ×
Specializes in Home Health/Hospice.

Depends on the situation if the patient is SOB, is that normal? change in mentation, have your VS ready, have allergy list on hand, have med list on hand, recommend to the doc what you feel is going on and what you feel will help, if SOB get lung sounds, listen to the heart. Is there chest pain? It all just depends on situation

Up Vote Up Vote ×

Vital signs & chief complain for starters. If it's a cardiac and or critical patient you may want to look at recent labs and have those ready to rattle off or atleast be sitting in front of the screen. You may want to glance on the IV pole and familiarize yourself with an anti biotic or something they might be getting.

Up Vote Up Vote ×
Specializes in Med/Surg.

Depends on why you are calling and the doctor's preference. We have a surgeon who is well known for asking random questions because he EXPECTS you to know about his patient before calling him. So its 0300 and the patient is in pain, better get a fresh set of vitals, empty the foley, any drains, see how high they can do their IS because its all fair game. Other surgeons, just tell them the patients name and what you want them to do or they think you are wasting their time. Primary/ Attendings are usually a little harder gauging how much info they want. I usually start with the bare minimum and then will add more depending on how the conversation goes.

For example.

Calling a surgeon who knows the patient in SBAR.

"Hi Dr. Bob, this is LouisVRN on the surgical unit at hospital name. (S) I am taking care of Jane Doe in room 5 she is complaining of some epigastric chest pain that radiates into her left shoulder. (B) She is POD1 s/p lap chole, hx of HTN, dyslipidemia. (A) Her vital signs are stable with current vitals being 115/70, 95, 18 96% on room air and temp of 98.9. She is tolerating clears without a problem, pain is being well controlled on morphine, she is not passing flatus. I did prophylacticly put her on 2L O2 so she is now sats at 99% and gave her 4mg of Morphine, which she said has brought her pain from a 9 to a 4. ® I just wanted to know if you wanted us to get a EKG and set of cardiac enzymes or if there is anything else that you would like done at this time."

Up Vote Up Vote ×

SBAR, baby.

Up Vote Up Vote ×
Specializes in Oncology/Hematology, Infusion, clinical.

There was a recent post about how to not feel intimidated when calling a doc that has some good information in it. Aside from what you think the doctor would want to know, I encourage having a quick way to access any info that he/she may ask readily available ( like emr, labs, reports, yadda yadda) so that even if it's not right there in your notes, you can find out quickly.

Up Vote Up Vote ×

i love you guys!! so much! :bow::hug:

Up Vote Up Vote ×
+ Join the Discussion