This is a way of communicating with Physicians about their patients that you the Registered nurse is taking care of. A good way of communicating with another individual.
S = SITUATION. Give a clear brief, comprehensive effective information about the problem at hand. For example Miss Jennifer came in with abdominal pain. Norco 5/325mg po given but ineffective. Pain 8/10.
B = BACKGROUND. Give a brief description and important information about patient history in relation to the current situation. Patient has history of recurrent abdominal pain. Allergy to Morphine sulfate. CT scan of abdomen done. It must be clear and relevant to current situation.
A= ASSESSMENT. What is your analysis of the problem. What is your assessment?.What are your clinical findings.She is crying and moaning, blood pressure 144/80.
R = RECOMMENDATION: What do you think?.What is your recommendation?.What do you want done for this patient. Doctor Nguyen can you please order dilaudid 1mg intravenously x1 for the patient and also medication for nausea and Vomiting.Doctor what do you think?.The doctor will then give you orders of what he want for the patient. Or he might put the order in himself.
Nurses You Move Me 