Situation
Johnny B. Good, 3B
What is patient name and room number?
Baseline HR 95, RR 20, BP 120/76, Temp normal
What are patient's vital signs?
I am hearing crackles and wheezes throughout.
What is reporter's assessment?
We need an order for oxygen.
What is a request?
Family Birthing Center
What is the department or location?
Peanuts, Penicillin, and Latex
What are allergies?
Forehead abrasion and Laceration approximately 7cm.
What is an injury?
What time can we be ready for you?
What is a request?
Suzy B. Goodness, Charge RN
Who is the reporter's name?
Chronic Kidney Disease
What is a diagnosis?
Oxygen saturation dropped from 93% to 82% on room air 4 hours.
What is urgency of patient's change in condition?
It's postop day 3; may we discontinue the Foley?
What is a recommendation/request?
New onset shortness of breath
What is patient's new symptom?
What are medications
Pupils are not equally reactive to light. I'm worried it might be a brain injury.
What are clinical impressions or concerns?
Would you like a set of orthostatic vital signs?
What is a recommendation/request?
Worsening right hip pain
What is patient's current condition?
Patient denied pain on admission
What is patient's baseline condition or status?
Patient becomes unresponsive and without a pulse
What is a Code Blue or 9-1-1 call (after checking POLST)?
Consider CT angiography to rule out vascular cause
What is a recommendation?