I remember as a Nursing student and as a new grad RN, I would get so nervous calling the provider. My heart rate would go up and my palms would get sweaty. Here are some of my tips to calling the provider.
I use SBAR! By using this I’ve had provider’s tell me that I always give the best reports!
S- Situation
“Hi This is ____(with your credentials)__ from __(floor/building/unit)___ . I am calling about ___(patient first and last name & DOB)__. I am calling you because (why are you calling? What is wrong with your patient). I am calling because I am concerned about this _____”.
B- Background
“The patient has a diagnosis of __(diagnosis that is related to your concern and other co-morbitites or background information that is pertinent in your situation)__. The patient’s baseline is _______. The patient is allergic to ____(Name your patient’s allergies if you are going to request/recommend any medications.)
A- Assessment
“At this time my patient is currently….
- Mental status is __(A&O, confused ect)___
- Vital signs are (Temp, Pulse, Resp, B/P, o2 and pain level) ….sometimes you’ll need to include other assessments such as blood sugar ect.
- Medications that are necessary to report
R- Recommendation
“Due to the situation, would you like to ______(order labs, start antibiotic ect)….
When receiving orders over the phone or verbally ALWAYS repeat them back! CBC CMP can sound a lot a like! Also verify again that the patient is not allergic to any new orders that you receive.
Here is an example of a SBAR!
S Hi Dr. Smith, this is Amanda a nurse at the Maine State Prison working in the clinic. I have a patient her John Doe DOB 9/9/9999 he’s 99 years old. I’m calling you because he presented to the clinic with a wound on his lower left leg.
B He has a diagnosis of hypertension and diabetes. According to his records he has been non-compliant with his diabetic medication and has refused his insulin the past 2 days. The patient is allergic to penicillin. He is alert and oriented at baseline.
A At this time his vitals are 99.0, pule is 90, R-18 bp is 160/86 and he 02 is 98 on room air, his current BS is 350. The wound is located on his left lower leg on his outer ankle, the wound is open and draining purulent drainage. The skin around the wound is hot to touch and painful. He rates the pain 7/10. The wound measures approx. 4cmx4cm and is about 1cm deep. He has not had any prior treatment. He states he got it from his new boots.
R I think we should start an antibiotic. Would you like to do a wound culture first? Would you like any labs? Would you recommend any special wound care and how often would you like it changed? Can we have parameters on his BS? I would also like to bring in a diabetes specialist to provide education to this patient, can I have a referral?
Ok So you would like a wound culture done and then start Bactrim DS BID x 10 days. You would like a CMP and CBC. Wound care is to be done daily until healed. The wound should be cleaned with NS and apply aquacel AG. You are making a referral to a diabetes specialist. You would like us to call the provider if his BS > 450.