NR 557 Week 6 Clinical Referral Write-Up Example

Referral Write-Up: The 11:40 Call to the Patient's Named Nurse Practitioner and the Handover to the Ambulance Crew, With Every Value Timed and One Sentence Saying What the Home Examination Settled and What It Could Not

Student Name

College of Nursing, Chamberlain University

NR 557: Health Assessment for Professional Nursing Practice

Instructor Name

Month Day, Year

Referral Write-Up: The 11:40 Call to the Patient's Named Nurse Practitioner and the Handover to the Ambulance Crew, With Every Value Timed and One Sentence Saying What the Home Examination Settled and What It Could Not

To Whom

The referral went to the patient's primary care nurse practitioner, who was on call for the practice that morning and whose direct number is on the home health agency's contact sheet for this patient. It did not go to "the practice" or "the on-call service," because a message addressed to a service belongs to nobody who reads it. I reached the nurse practitioner by phone at 11:40, confirmed who I was speaking to by name and confirmed that the nurse practitioner had the patient's record open. A second handover was given at 12:25 to the ambulance crew who transported the patient, and a written copy went with the patient to the emergency department.

The Call, Structured

I used a situation, background, assessment and recommendation structure, which gives both people on a call a shared order of information and has been used to improve communication between clinicians (Haig et al., 2006). The call, as given, is summarized below.

Situation. "I'm calling about a 78-year-old patient with COPD and heart failure whom I'm seeing at home now. The patient has new breathlessness at rest, fever and new confusion, and I'm concerned about pneumonia with early sepsis."

Background. "COPD for 12 years, two admissions for exacerbations in three years; heart failure with a weak left ventricle; former heavy smoker. Cough with yellow-green sputum for three days, breathless at rest since yesterday evening, slept in a chair. Rescue inhaler four times since last night. Daughter reports confusion this morning."

Assessment. "At 11:05 to 11:20: respiratory rate 28 counted for a full minute, oxygen saturation 88% on room air, which is usually 92 to 93 for this patient, heart rate 104, blood pressure 128/74, temperature 38.3 orally. Right base: dullness, increased fremitus, bronchial breathing and crackles; left base clear of crackles. Jugular pressure not raised, weight 0.8 kilograms above dry weight, ankle edema unchanged. Disoriented to day and month, can't do months backward; fully oriented at previous visits. I think this is right lower lobe pneumonia with signs of sepsis; the patient meets two quick sepsis criteria, respiratory rate and altered mentation."

Recommendation. "I recommend emergency department evaluation today, by ambulance because the patient is breathless walking and saturation is low. Do you agree, and is there anything you'd like done before transport?"

The nurse practitioner agreed, asked me to call an ambulance and said the practice would notify the emergency department.

Findings With Times on Them

A single set of values is a snapshot. A referral that gives times lets the reader see a direction. Before the ambulance arrived, I repeated key measurements.

11:05: respiratory rate 28, saturation 88%, heart rate 104.

11:20: temperature 38.3 °C, blood pressure 128/74.

11:55: respiratory rate 30, saturation 87%, heart rate 108, blood pressure 124/72; patient still disoriented to day.

12:20: respiratory rate 30, saturation 88%, heart rate 106.

The direction was not improving. The respiratory rate rose from 28 to 30, which would add a point to the CURB-65 severity score, which counts a rate of 30 or more (Lim et al., 2003). That change was passed to the ambulance crew.

The Sentence That Draws the Limit

The written referral included one sentence stating the limits of a home examination: "The home examination establishes new right basal consolidation, fever, tachypnea, low saturation for this patient and new confusion, and does not establish the cause of consolidation, oxygen requirement on testing, blood counts, renal function or lactate, or whether heart failure is contributing, all of which need hospital assessment."

That sentence tells the receiving clinician what can be relied on and what must be checked. It prevents two opposite errors: dismissing the home findings because they were not obtained in hospital, and treating them as a diagnosis that needs no testing.

The Handover to the Ambulance Crew

The ambulance crew received a shorter handover at 12:25 covering the same four headings, the timed values and the fact that the patient's usual saturation is 92% to 93%, so they would not judge 88% against a general COPD range. I also gave them the medication list, the heart failure clinic's dry weight, the daughter's phone number and the patient's stated wish to avoid a long emergency department stay, which the crew said they would pass on. The daughter traveled with the patient.

What the Receiving Clinician Needs Most

A receiving clinician in a busy emergency department has limited time to read. The referral was built so that the three most useful pieces of information came first: the counted respiratory rate with its trend, the patient's usual oxygen saturation and the new confusion compared with baseline. Those are the facts most likely to be lost in transfer. Emergency staff seeing a patient with COPD and a saturation of 88% might judge it acceptable without knowing the patient usually sits at 92% to 93%. A patient who is oriented to place might seem clear unless someone says that they were fully oriented a week ago and cannot say the month today.

The referral also included what the home health agency could offer on discharge: a visit within 48 hours, weight monitoring and a nurse who knows the patient. That information helps the emergency team decide whether the patient can go home after treatment, because a safe discharge depends on the support available at home, not only on the patient's condition.

Documentation

The home health note records the call time, the name of the nurse practitioner, the recommendation made and accepted, the ambulance request time and arrival time, the handover and the timed values. It records respiratory rates as counted, with the duration of the count. A later reader, including a surveyor or a clinician reviewing the admission, can see what was known at each point and why the patient was sent. Respiratory rate is so often estimated in routine records (Badawy et al., 2017) that recording how it was obtained is part of making the referral credible.

Taken together, the call, the timed values and the written limits sentence gave the emergency team a picture they could act on immediately.

The nurse practitioner confirmed receipt of the written copy that afternoon.

References

Badawy, J., Nguyen, O. K., Clark, C., Halm, E. A., & Makam, A. N. (2017). Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Quality & Safety, 26(10), 832-836. https://doi.org/10.1136/bmjqs-2017-006671

Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Patient Safety, 32(3), 167-175. https://doi.org/10.1016/S1553-7250(06)32022-3

Lim, W. S., van der Eerden, M. M., Laing, R., Boersma, W. G., Karalus, N., Town, G. I., Lewis, S. A., & Macfarlane, J. T. (2003). Defining community acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax, 58(5), 377-382. https://doi.org/10.1136/thorax.58.5.377