MDS Alert
Calling The Doctor: Guidance For Nurses
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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