The sentences that stop the interview
Triage each finding, then press Check my triage.
If a red flag appears mid-history, you do not finish the family history first. Stop, assess airway–breathing–circulation, obtain a full set of vital signs, do not leave an unstable or actively suicidal patient alone, and escalate. The rest of the history can be completed later; the window on a stroke or an infarct cannot be reopened.
Learn them as a set. Chest pressure with diaphoresis, dyspnoea or radiation to jaw or arm · sudden severe headache described as the worst of the patient’s life · new facial droop, one-sided weakness or speech change — get the last-known-well time before anything else · airway symptoms after a new medication (lip or tongue swelling, throat tightness, stridor, hives) · haematemesis, melaena or syncope · suicidal or homicidal ideation with plan or means · disclosure of abuse with immediate danger · and any patient who reports a sense of impending doom, which is a genuine clinical sign, not an anxiety symptom, until you have proven otherwise.
—of 12 items placed correctly
Place each item, then press Make the call.
Before you dial, have the chart, the last set of vital signs and the medication list in front of you. After you hang up, read back any orders you received, and document the call with the time, the person notified and the response. An escalation that is not documented did not happen.
The R is where students go quiet
Situation, Background and Assessment are description;
Recommendation is a request, and it has to be specific and time-bound. “I’d like a 12-lead ECG now, cardiac markers, and an order for aspirin. Can you come see him, or should I activate rapid response?” In an acute stroke the R also carries the single most important number in the call:
last known well, because it determines eligibility for thrombolysis and thrombectomy.
Your entry
Tick your elements, then press Build the entry.
Four requirements. Documentation of a history is timely, objective in tone, specific in measurement and attributed to a source. Quote the patient for the reason for seeking care and for anything clinically or legally significant. Use “reports,” “states” and “denies” rather than “complains of,” which reads as judgment.
Never chart opinion about character — “drug seeking,” “uncooperative,” “poor historian.” Chart the behaviour you observed instead. Never chart care before it is given, never chart for another person, and correct errors according to policy — single line, initial, date, addendum — never by erasing or deleting.
What may never be delegated
Assign each task, then press Check my calls.
The five rights of delegation: right task, right circumstance, right person, right direction and communication, right supervision and evaluation. The RN who delegates retains accountability for the outcome.
“Just take a set of vitals” is not a delegation
A delegation names the
task, the
timeframe, the
reporting parameters and
to whom to report: “Please take Mr. Alvarez’s vital signs now and tell me right away if his heart rate is over 110, his systolic is under 100, or his oxygen saturation is under 92.” If you would not want to defend the instruction in a deposition, rewrite it before you say it.
Ask the UAP what they noticed. Unlicensed assistive personnel may — and should — report what a patient told them, and their observations are valuable raw data that you then interpret. What they may not do is collect the history, decide what a symptom means, teach the patient, evaluate the effect of an intervention, or take vital signs on an unstable patient whose readings will drive an immediate decision.
Finding it on every skin tone
Choose a finding, then choose where you would assess it.
Assess in natural or bright white light, compare with the patient’s own baseline and adjacent skin, and always use the mucous membranes and palms as a check. Skin tone changes how findings appear, and describing every abnormality as “redness” is both inaccurate and a documented source of missed pressure injuries and missed hypoxia in patients with darker skin.
Palpation is the equaliser. Warmth, induration, oedema, a boggy or firm texture, a temperature difference from the opposite side, and the patient’s own report of pain are all readable on every skin tone — and none of them depend on seeing a colour. When the visual finding is unreliable, the hands and the patient’s report carry the assessment.