- Identify: state who you are, where you are calling from and the name of the patient
- Situation: describe your concern and the reason you are calling
- Background: state a brief history of why the patient was admitted, any relevant past medical history, current treatment and important investigation results
- Assessment: give your assessment of the patient’s condition including vital signs, whether stable or deteriorating, your clinical impression and immediate concerns
- Recommendation: state exactly what you would like to happen, making clear suggestions and clarifying your expectations
Hello (Registrar Name), sorry to call you so late, (Your Name) here. I just wanted to let you know I am on Ward X seeing a 74-year-old lady Mrs Y, She had an unwitnessed fall on her way to the bathroom with no prodromal symptoms. Although she only has a bruise on her left thigh, I just wanted to check I had not forgotten anything.
Mrs Y was admitted 10 days ago with poor mobility on a background of known rheumatoid arthritis, chronic renal failure and type 2 diabetes mellitus. I note she has had three previous falls this admission, and is on diuretics and sleeping tablets. Her last urea was 12 and creatinine 180.
Her vital signs are OK with a slight tachycardia at 104, but normal BP for her at 140/85. Her resp rate is 36, but she is upset at all the fuss, and her sats are normal on room air. Otherwise, I really could not find anything abnormal examining her, apart from a 7x9 cm bruise on her thigh, with no underlying bony injury as she can still walk unaided. I think this was most likely a mechanical fall, maybe related to her tablets, and I have given her some paracetamol.
I have asked the medical team to reassess her mobility in the morning. Should I come back later to see her myself before that, only I still have another five calls to complete?