PN4D

I-Introduce Yourself: Introduce yourself and your role in the patient’s care

State the unit you are calling from when speaking with a physician over the phone

S-Situation

Specify the patient’s name and current condition or situation. Explain what has happened to trigger this conversation

Patient name: ____________________________ Room: ___________ Sex/Age: ___________

Diagnosis: ____________________________________________________________________

B-Background: State the admission date of the patient, their diagnosis, and pertinent medical history.
Give a brief synopsis of what’s been done so far (e.g., lab test)

History:

Allergies:

Labs:

A-Assessment: Give a summary of the patient’s condition. Explain what you think the problem is or say, “I’m not sure what the problem is, but the patient is deteriorating.” Expand upon your statement with specific signs and symptoms.

Current VS: T: ______ P: _____ BP: ____/_____, RR: _____, O2Sat______ @ _________(O2)

Heart Rhythm: ___________________________ Lugs sounds: ____________________

Blood Sugar: ____________ LOC: __________________

R-Recommendation

Explain what you would like to see done (e.g., lab tests, treatments, or “I need you to see the patient now”) State any new treatments or changes ordered (e.g., monitoring and frequency or when to re-notify the physician if there is no improvement in the patient)

R-Read Back: repeat any orders received back to the prescriber for accuracy.