information from the patient's chart, flow sheets and progress notes. For example:
‘Mrs. Taylor is a 69-year-old woman who was admitted from home three days ago with a community-acquired chest infection. She has been on intravenous antibiotics and appeared, until now, to be doing well. She is normally fit and well and independent.’
A: Assessment
• Vital signs
• Clinical impressions, concerns
An example of what you might say or write is:
‘Mrs. Taylor’s vital signs have been stable from admission but deteriorated suddenly. She is also complaining of chest pain and there appears to be blood in her sputum. She has not been receiving any venous thromboembolism prophylaxis’.
You need to think critically when informing the doctor of your assessment of the situation. This means that you need to have considered what might be the underlying reason for your patient's condition. Not only have you reviewed your findings from your assessment, you have also consolidated these with other objective indicators, such as laboratory results.
If you do not have an assessment, you may say:
‘I think she may have had a pulmonary embolus.’
Or
‘I'm not sure what the problem is, but I am worried.’
R: Recommendation