5 Questions to Ask Before Calling the Doctor

Sep 14, 2019 | 0 comments

5 Questions to Ask Before Calling the Doctor

Communication is an essential element in coordinating patient care in every clinical setting. Communication within the hospital is especially important due to the fact that there are often critical patients, and a patient’s status can change at any second. In order to convey this change of status accurately and provide the patient with the best care possible, it is imperative for the nurse and the provider to have great communication.

As a nurse, sometimes it can be difficult to know just what your patient needs. When you don’t know – it can be nerve-wracking trying to decide your next action. Do you call the doctor immediately, do you just ignore it and hope for the best, or do you have to call an RRT?

When you’re unsure – it’s common to call the doctor or provider because that is a frequent solution as they often know what to do. However, not every patient issue needs to be called to the provider. Decreasing these unnecessary calls can increase your efficiency and problem-solving skills, but additionally will allow the providers to be more efficient as well. To help you with the decision-making process – these are 5 questions to ask yourself before you call the doctor.

1. Is the Patient Stable?

Learning to be a great nurse involves learning how to prioritize. Whenever there is a change in patient status or a reason to call the provider, always ask yourself – “Is the patient stable?”. This will oftentimes seem obvious but calling a Rapid Response can be nerve-wracking. What if you call one and everyone thinks you’re dumb because it wasn’t necessary? This is a common worry as a new graduate RN. As you gain experience in nursing – you will be able to more easily be able to identify the need for an RRT when it presents itself. However, in order to assess your patient’s stability – you really must do two things first (in this order!):

Physical Assessment

You must lay eyes on your patient. Let me repeat that – YOU MUST LAY EYES ON YOUR PATIENT. You may not even need to touch the patient and already acknowledge the need for immediate emergent intervention. If they are unresponsive and not breathing and/or don’t have a pulse – you can immediately activate an emergency response (CODE BLUE). However, it won’t always be so black and white – so the next step is to assess their vital signs.

Vital Signs

Obtaining a new set of vital signs is imperative in order to assess the stability of a patient. “Is the patient stable” really just means “are their vital signs stable”. A patient who doesn’t have a pulse has a HR of 0 – so you don’t need to grab the Dynamap and grab a full set of vitals (spoiler – they won’t have any!). But it’s usually less clear. The patient may have increased lethargy, increased SOB (but not in acute respiratory failure), new chest pain, or any other changes of status. Getting these patient’s vital signs will determine whether or not they are stable. A patient who is SOB, in the tripod position, has an SPO2 of 80% on 4L NC, and RR of 48 – this patient needs an RRT or whatever emergency response team activated immediately. A patient with COPD who is moderately SOB, is 88% on 2L NC, and RR of 28 and mildly labored – this patient can likely be handled over the phone with changes in respiratory treatments and oxygen therapy.

If the patient has been deemed stable – you can move onto the next question.

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2. Is there more information I need to know first?

This will obviously depend on the situation and will require some investigation. If the patient is SOB – what is their history? Do they have any related diseases such as Asthma, COPD, or CHF? If they have back pain – have they had this before? What do they usually take for it? It’s possible the same complaint or situation may have happened earlier in their hospital stay – what was done about it and how did the patient respond?

Investigating trends in their labs or vital signs is also important. If a patient’s blood pressure is 180/90 – what has their BP been running? The same holds true for hypotension. A patient whose BP is 90/40 but who’s baseline is 90s/40s is important to know. If you get a call for an elevated troponin or lactic acid level – what were their previous levels? Note all of this information for when you have to call the provider – so you can anticipate what they will ask and assist them in making the appropriate clinical decision.

The next important step is to check the orders that already exist.

3. Are there any PRN orders?

Many times patient’s will have “PRNs” or medications “as needed” that are already ordered by the provider. This means they have a medication or order which can be used for pre-established reasons that the provider must list. Look at their MAR and see if they have any PRN medications.

Some frequent PRN medications are as follows:

  • Melatonin 3-9mg PRN for sleeping difficulty
  • Acetaminophen 650mg Q4H PRN for Fever > 101.4 F
  • Ondansetron 4mg IV PRN for nausea or vomiting
  • Morphine 2mg IV Q4H PRN for severe pain
  • Hydromorphone 0.5mg IV Q4H PRN for severe pain
  • Ketorolac 15mg IV Q6H PRN for moderate pain
  • Hydralazine 10mg IV Q6H PRN for SBP >160
  • Ipratropium-Albuterol Inhl Q4H PRN for SOB or wheezing

Other Frequent PRN orders include:

  • Oxygen via NC PRN – titrate SPO2 > 94%
  • Heating pad PRN for back pain
  • The patient may shower PRN

No matter the PRN order – it is your job as the nurse to look for which PRNs are available to you, and if you can utilize them accordingly. If your patient above who is mildly SOB and wheezing with a history of COPD – give them one of their Duonebs if it is appropriate. If they just received a treatment and still have not improved – then calling the provider is likely necessary.

Also check out my Nursing Medical Abbreviations graphic!

4. Can I phone a friend?

Sometimes we may not know what to do with our patients, but we may also be unsure if we need to call the doctor for it. Asking a fellow nurse’s opinion on what needs to be done for your patient can improve your problem-solving and clinical judgment. Your nursing colleagues, especially those with more experience or even just more skill in a particular area – may be the perfect person to ask of their nursing opinion. Do they feel like its necessary to call the doctor – or is there a nursing intervention that can be tried first instead? Are you unsure of what EKG rhythm you are reading and think you might see a run of VTACH but aren’t sure – ask a nurse who is good at rhythm interpretation.

Now I am NOT saying that asking a fellow nurse is a replacement for calling the provider. However, sometimes bouncing ideas off of our colleagues can save us from having to make an unnecessary call. Even calling the nursing supervisor may be a resource which you can utilize if appropriate. However – for a new significant change in patient status or vital signs – the provider will need to be called regardless.

5. Am I calling the right person?

OK – so you know that you’ve exhausted your other options, you have the background information you need… now you just need to actually call the provider. But make sure you are calling the right provider. First – check to see who the attending physician is on record. Is there an in-house medical team such as a hospitalist group, house coverage, or medical resident team that covers that attending? If not – you may need to reach out directly to the attending physician’s service to speak with whoever is on call. This will be facility-specific, so you may not always know if you are new. This is where asking your colleagues for assistance can benefit you.

Reaching out to the medical team (listed above) is common and usually, they can help! However, sometimes they are not the right person to be notified in certain instances. Are there any specialists on board? If Infectious Disease is seeing a patient and there is a positive blood culture – it would be better to put a call out to them instead. If a patient who is on dialysis has uncontrolled high BP, placing a call to nephrology would be a better choice as well. You can reach out to the general medical team – but don’t be surprised if they ask you to place another call to the specialists instead.

Now you are fully prepared to make the phone call and accurately communicate what is going on with your patient, you will have investigated the background information, you will have obtained vital signs and done a quick assessment, and you will have recommendations for medications or orders at the ready (thanks to the other nurses you’ve asked!). As you can see – this perfectly sets you up to provide a great phone report to the provider! To learn more about giving a great phone report to a provider and steps to calling the doctor – you can read all about it here!

Calling the doctor doesn’t have to be scary. If you critically think your way through these important steps, and utilize my IMSBAR communication style – you WILL succeed and you will be amazed at how far a little preparation can go.

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Calling the Doctor – Giving Nurse to Provider report

Sep 10, 2019 | 4 comments

Calling the Doctor – Giving Nurse to Provider report

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When I first started working as a bedside RN, one of the aspects of the job that gave me a deep sense of anxiety was having to call the doctor on a patient. Sure – some of them were super nice – but many of them were impatient and rude. Not giving the correct phone report in a format that the physician or Advanced Practice Provider (APP) is looking for can create tension and miscommunication. If you utilize my technique for giving phone report to the physician – the patient’s situation will be more effectively communicated and the encounter will go much smoother.

In this article, I am going to share with you all an effective method for giving a quick report to the physician or APP when you call them in the inpatient setting! I am uniquely positioned to help with this because I work as a Nurse Practitioner in the hospital and receive 20-30 calls per night from floor nurses. I have noticed many improvements that can be made to improve communication – so keep reading!

Step 1: Introduce yourself and the patient

“Hi, My name is Michelle and I’m calling from 1G. I’m the nurse taking care of Anita Lopez in 230-2. Are you familiar with her?”

First you need to introduce who you are, where you’re calling from, and who you’re calling about. I can’t tell you how many times the nurse has called me and launched into a full explanation about the patient and then I have to ask “Who is the patient!?” Oftentimes the inpatient Provider is at the computer and can look up the patient’s chart while the nurse is talking.

Sometimes over the phone it is difficult to understand last names – especially if accents are involved. When you say the patient’s name, it helps if you say “Anita Lopez, that’s L-O-P-E-Z”. Spell out the last name because oftentimes we have censuses pulled up from each floor or hospital which are ordered alphabetically. We usually do not need the spelling of the first name.

It also can be helpfult to include where they are located – their unit and room number. Additionally – the Provider you are calling may only cover certain attending physicians (as is the case at my job). If this is so – give the attending physician as well.

The next step is to ask if they are familiar with the patient. If I just admitted the patient – I don’t need a full explanation of why they’re here and what their medical history is. However, many specialists or Providers who are on call may not be very familiar with the patient yet. It always helps to ask and most Providers won’t give you an issue by asking.

Step 2: Brief Medical History

“She’s a 78 year old female who came in on 11/28 for a COPD exacerbation. She has a PMHx of COPD, Smoking, Hypertension, Hyperlipidemia, and afib which she’s on Coumadin for”

In the inpatient setting – I always want to know why the patient was admitted. This gives some context to the patient’s situation. If a patient who came in for COPD exacerbation is complaining of a headache – that typically deems less investigation than a patient who came in for a TIA or a mechanical fall and is now having a headache.

Additionally, a brief overview of their medical history should be given with emphasis on important/related diseases. Hit the following:

  • Cardiac: HTN, CAD (any stents or CABG?), Afib (anticoagulants?), CHF
  • Pulmonary: COPD, asthma, Lung cancer
  • Renal: AKI, CKD, ESRD (on dialysis?)
  • Vascular: DVT/PE, PAD/PVD

You usually don’t need to go into any details regarding surgical history unless it is directly relevant to this admission in some way.

Step 3: Why You’re Calling (SITUATION)

“The patient is complaining of increased SOB”

This is pretty simple. Why are you calling the Provider in the first place? Usually this is due to :

  • A new complaint: Chest pain, SOB, Headache
  • A medication need: sleeping medication, breathing tx, pain medicine
  • A change in the patient’s status: Respiratory distress, Unresponsive, confusion
  • A critical lab value : elevated troponin, elevated lactic, positive blood cultures

No matter why you’re calling – simply state it and then jump into the following step – the background of the situation.

Step 4: Situation Background

“They are ordered duonebs q6h but has nothing ordered PRN”

By this point you already given the important information such as who you are, who the patient is, where they are, why they were admitted, and why you’re calling. Now you can get to the heart of the call and give context to the situation at hand.

In this instance, the patient is SOB and has COPD. Are they ordered breathing treatments and how often? No matter why you’re calling, it helps to ask these questions:

  • Has this happened before and what was done? Did it help?
  • Are they currently on any medication for the situation?
  • What trends have been occurring (i.e. if you’re calling for high BP, how have their BPs been?)

Investigating the background of the situation can really help communicate the correct need to the Provider.

Step 5: Assessment

“The patient’s RR is 24 rpm and SPO2 is 90% on 2L NC. They’re breathing is non-labored, lung sounds show expiratory wheezes throughout”

As the nurse, you are responsible for assessing the patient first when there is a change in their status. This doesn’t mean you need to do an entire nursing assessment and report that, but get their vital signs and a do a quick physical assessment of the systems involved (I.e. If you’re calling for SOB – tell me how they are breathing and what their lungs sound like).

Please make sure you get an UPDATED set of vital signs whenever there is a change in patient status. Their vital signs from the 3-4 hours ago are not helpful to the current situation (depending on why you’re calling). That’s just good practice.

Step 6: Recommendations

“Can you please add albuterol PRN for inbetween scheduled duonebs”

Nurses are the eyes, ears, and hands of health care. They are on the front lines, are well-educated, and usually have great recommendations to help their patient. Maybe you know just what the patient needs to feel better.

Another important recommendation is asking if the Provider can evaluate the patient in-person. Sometimes it is difficult to convey your uneasiness about how a patient looks – even if their “numbers” look fine. Asking the Provider to personally evaluate the patient (if needed and indicated) is a great way to ensure the patient is in good hands.

Related Content: Tips for New Nurse Practitioners

– – – – – –

So Yes, it is SBAR, but with some important introductory steps beforehand. But what if you’re a Provider and need to know how to call consults to other Providers? I’m going to let you in on a secret – these steps are exactly what I do when I call a Provider for a consult as an NP. There really is no difference between a good nurse-to-provider report or a provider-to-provider SBAR.

As long as all the relevant information is conveyed in a concise and organized manner, you will be sure to impress the Providers you are calling, and ensure that proper communication is maintained – giving your patient the best possible care.

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Top 6 Charting Tips for Newbie Nurses

Apr 20, 2018 | 11 comments

Top 6 Charting Tips for Newbie Nurses

The joys of nursing: making a difference, decent pay, and… charting!? Adjusting to the new role as a medical professional is exciting, but unfortunately, there is SO much to learn that nursing school unfortunately just can’t teach you.

One obstacle that new nurses face is learning how to chart quickly and effectively. Learning a new computer system, especially when you’ve never even professionally charted, can be daunting.

Learning time-management and charting skills are difficult enough, let alone actually taking care of the patients! Use these Top 6 Charting Tips for Newbie Nurses to help you transition into the nursing role and help you chart like a pro!

1. Have a System

A critical factor in organization and time-management as a nurse is to have a system for whatever you do. If you go through a literal checklist, you are less likely to miss something, especially as a new nurse!

It can be difficult to chart an entire patient encounter and not miss details, and going through your personal system that you’ve created can help you minimize charting errors. Remember this charting tip throughout the rest of the tips below – developing your personal system is critical in your time-management as a nurse.

Knowing where you write things down, where you chart things, and in what order will help you stay organized in a chaotic environment.

Your system should be flexible as patients and hospitals can be unpredictable. With time, you will be able to adjust your system to be less task-oriented and more holistic.

2. Write it Down

Something that almost EVERY organized nurse does is write down their patient information in some form or another.

You are probably somewhat familiar with this as you likely wrote down every piece of information you could in clinicals. But now you’re in the big leagues – you are responsible for your patient and the information you write down is important.

Seeing multiple patients with similar scenarios, it is easy to forget specific information or mix up information between two similar patients. What you write down will be your brain.

When a physician or other medical professional asks you a question about your patient – the last thing you want is to NOT know! Even if it takes you 10 seconds to find on your paper – this is better than saying “I don’t know”, and physicians and other healthcare staff will respect that.

Many different electronic medical records (EMRs), especially within the hospital, will have printable “patient care sheets” which can provide you with information in the medical record such as the patient’s demographics, medical history, ordered medications, and recent labs.

This can be VERY helpful – but you must have a system in place. Find a specific place to write down the information that isn’t pre-populated.

Where is their IV and what gauge? What is their history of present illness, aka what brought them into the hospital? Find specific places to write this information down on the sheet, and this will help you stay organized and be able to draw accurate information quickly and efficiently for accurate patient charting.

Quickly write down your patient assessments, as well as any new information the patient presents. I also recommend writing down vital signs on your sheets as well to be able to monitor and trend them accordingly. Sometimes when just reading them on the screen, you can miss important information.

Learn your medical abbreviations. If there’s not one – make it up! As long as YOU understand what you are writing – it serves its purpose. This will save you time AND wrist-pain.

If you’d like, I have free patient care organization sheets which you can print and copy to write down patient information and stay organized. You can sign up with your email for free here.

One last note – write down your times; the time you assessed them, the time you emptied their urinal, the time you assisted them to the bathroom, you get the point.

I can’t even count how much time I wasted trying to estimate what time I performed some sort of patient care because I didn’t write it down.

3. RTC

This is probably my BIGGEST recommendation – learn to chart it in real-time.

This is one of the key skills I’ve learned which tremendously helped my first year on a telemetry floor, and subsequently my time in the emergency department.

This is easier if you have a portable computer on wheels, as many units will. By real-time, I don’t mean while the patient is talking. Focus on the patient and give them your undivided attention and assessment skills.

Chart directly AFTER your patient encounter, exit the room (or stay in), and set aside 5 minutes or so to chart everything that occurred right outside the room.

This accomplishes a few things:

  • Everything is FRESH in your mind, and your charting will be more accurate.
  • If you realize you forgot to ask or assess something and realize it while you are charting, you can just walk right into the room and ask/assess the missing information. This happens much more than you expect!

As a new nurse learning a new charting system, you may not be able to finish the entire chart within 5 minutes. If not, I recommend still setting aside about 5 minutes directly after seeing the patient to chart.

Start with your patient assessment, as this is what will be the most difficult to remember specifics later on (you’re going to be doing 5+ assessments).

If you do not get to your patient care plans, patient education, tasks, or another facility-specific charting, that is okay! You can chart this information when you have some downtime later. Just keep a checklist and know what else needs to be charted to come back to later. You will get quicker with time!

4. Nancy Drew it

Once you get to know the electronic medical record, you can really start to use it to streamline your patient care and investigation skills.

One way you can utilize the system is to find information that you didn’t write down (like you should have). One common way I “Nancy Drew’d It” was when I forgot to write down times I performed patient care.

You can go back into the system and cross-check your times. By this I mean, look to see something already charted in the system that you can relate back to when you performed the task.

Did you administer the patient’s medications 10 minutes after your assessment? Look into the EMAR and see what time the medication was administered (already charted in the system), and subtract 10 minutes. Easy enough right?

Learning the EMR and being able to navigate it quickly and efficiently will help you gather appropriate patient information. Learn to look back at old labs (I’m talking 6-12 months ago.. What exactly is their baseline creatinine?), at old medication lists, at imported data from primary care offices, pharmacy information, and at History & Physicals from previous admissions.

Your specific charting software will limit or expand your ability to do this, but all EMR software will have ways of gathering information which you will learn to navigate with time.

5. Work Smart!

As a nurse, you work hard enough! When you are able, try working smart!

If your EMR allows, duplicate a previous assessment and adjust what needs to be changed based on your assessment. Whether it is your assessment or another nurse’s, it really doesn’t matter – just make sure that the charting reflects your actual assessment.

This mainly just saves you mouse clicks – but also your valuable time.

Providers have shortcuts with charting as well. When dictating or typing their H&Ps, they often utilize “macros” or templates that list out a normal Review of Systems and Physical Exam. They change what needs to be changed and it allows them to chart relatively quickly.

Unfortunately, nurses tend to have to chart in a less convenient way, which usually involves multiple clicks, checkboxes, and forms. This is convenient for coding and billing, as well as for insurance companies for data mining purposes, but it is NOT convenient for the nurses.

When the EMR allows, it will save you a good amount of time by duplicating an assessment. Some EMRs will have offer better functionality in this aspect, and others will not allow it at all. It will also depend on the facility and its policies regarding charting duplication.

6. CYA

Nurses are the backbone of the healthcare industry. Unfortunately, the responsibility of our patient’s health ultimately can trickle down to the RN taking care of them, and this can be stressful.

A nurse can find themselves in legal trouble if a medical error occurs and he or she did not catch it (or worse – caused it).

Due to the unfortunate trend in patients suing hospitals and staff, it is vitally important to cover yourself with your charting. Chart EVERYTHING that you can.

Always document each notification you made to the Provider, and the conversations you have with the patient/family. Use direct quotes when possible, even if what was said might not be rated PG…

When in doubt, inform your charge nurse or director of anything that you don’t feel comfortable with – and CHART it! By initiating the chain of command, you did your duty as the nurse.

Hopefully, with these charting tips, you’ll be a little less stressed about charting and able to focus more on what truly matters – patient care!

Drop a comment below if you have any other charting tips that will come in handy for new and experienced nurses alike! As always, let me know of any other blog suggestions you’d like written about!

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Nurse Charting Nurse Documentation Abbreviations