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Long-Term Care Survey Alert

Quality Improvement:

Calling The Doctor--Guidance for Nurses

Published on Mon Jan 28, 2008

Medical director provides suggested format for getting info in a row.

Nurses who prepare before calling the physician about a resident will be more likely to give the physician needed information to make a better decision, noted Bruce Robinson, MD, in a presentation at the American Medical Directors Association 2007 annual meeting. He suggested this reporting format for nurses.

Preparation: Review the chart including:

1. Recent medical notes

2. Recent nursing notes

3. Advance directive information

Script for evaluation and reporting:

Age:_________ Gender:_________ Terminal/CMO/DNR? ___________________________

Usual chronic conditions: ____________________________________________________

Presenting problem: ________________________________________________________

(Onset, duration, frequency, severity)

Related medical history: ____________________________________________________

Major medications (med changes, warfarin): ___________________________________

ROS- circle positives: Changes in alertness? Personal function? Bowel/bladder function?

Physical assessment: BP____ P____ T____ R___ PulseOx____ Looks acutely ill? _________

Mouth_____________________________________ Chest ___________________________

Abdomen _________________________________ Skin (edema?) _____________________

Pain? Agitation? Alertness?

Other findings _______________________________________________________________

Recent labs: ________________________________________________________________

Report of family contact: ______________________________________________________

Physician response: ___________________________________________________________

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