MDS Alert
Calling The Doctor: Guidance For Nurses
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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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