Critical Situation Call to the Physician or Nur Gather the chart and patient information before you make a call.
SBAR Checklist Critical Situation Call to the Physician or Nur Gather the chart and patient information before you make a call. Use this checklist to gather your thou Patient Namsharon Cole Patient DO63/15/1991 Date Time SITUATION Stephanie Smith, RN. I am calling NOTES Identify My Name is( Your name & tiffegg the Inpatient Orthopedic Unit I am calling fromame of facility or uabout(patient namSharon Cole The problem I am calling about is or I am concerned about BACKGROUND Admitting Doctor , PCP, or NP is Admitting Diagnos epolar Disorder Secondary Diagnos Sight Ankle Fracture Code status / DNR Allergies Vital Signs: T P R B/P Pain Statust 2 3 4 5 6 7 8 9 10 Location / radiationc Duration : Intensity o Changes in Severity _ Effectiveness of pain meds Current meds pertinent to the problem o Blood thinners: Antibiotics = Other There are changes in the following: + Neurologica Speech Pattern Numbness Paralysis: Weakness LOC= Alert and Oriented> Confused :Agitated = Combative : Lethargic = Unresponsiveo Delirium Respirators Pulse Ox reading: Oxygen @ _ Limin cannula = Difficulty breathing Breath sounds Cough Cardiovascular: Chest Pains Heart Rate Heart Sounds Regularity Pain : Edema GI Function Tenderness Distensions Nauseas Vomiting + GU Function: Catheter = 1/0 _ mL/hr = Pain on urination : Color Urine: Red = Pink : Straw colored: Dark = Concentrated Musculoskeletal Pain : Tenderness Alignments Mobility = Edema Skin: Temp = Dry = Moist :Clammys Mottled = Cyanotico Hives Wound status Induration : Drainage : Color = Wound Approximation Abnormal test resultabs : INR : Blood gases : Imaging results
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