| Introduction Identify yourself (name, job and location) Example: “Hello, I’m Andrea I am the nurse taking care of your patient William Jones in Room 502.” | |||
Situation Patient’s age and gender, their current status (are they stable yes or no), why are you calling? “I am calling because…” “I have noticed a recent change…” “I have received lab results…” Example: “Mr. Jones is a 90-year-old man who has been A and O x 3 I am calling because he is breathing at 32 breaths per minute and his pulse Ox is 84% on 2-liters nasal cannula.” | |||
Background Give the RELEVANT details (presenting problems and history), Is this an emergency? If yes say so RIGHT AWAY “He was admitted for…” (when were they admitted?) “He has a history of…” “He is allergic to…” Example: “He was admitted with Pneumonia yesterday. He has a history of COPD and CHF. He has become increasingly confused, and breathing has become labored. His hands and feet appear swollen.” | |||
Assessment What did you see upon assessment? “I think the problem is…” “I don’t know what the problem is but I have noticed these changes…” “I am concerned about…” “I have done (name interventions) Example: “The patient seems to be getting worse, I think it may be related to fluid overload. I have increased his oxygen to 4 liters.” | |||
| Recommendation/Request What do you want from the doctor? “I need you to come see the patient.” “I would like an order for…” “What would you like me to do.” Example: “I would like an order for Lasix and for you to come see him.” |
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