Patient Care Rounds Complex Postoperative Care Results: Sonia Best

hey

Greet

Hello.

how do you feel

Question

I’ve been better. Having some bad pain right now.

sorry for that

Empathize

Thanks. I think I needed to hear that.

whats your medication regime

Question

I have a small pillbox that I use to organize.

do you have medications allergy

Question

No medication allergies.

do you use medication allergies (Clarified to Do you have medication allergies?.)

Question

No medication allergies. (Clarified to if I have medication allergies.)

what pain medication are you taking

SBAR

Prompt

Learner Response

Model Response

Prompt:

Hi. I’m ready to take over care of this patient. Could you tell me what the situation is?

User Response

is in pain after leg amputation

Model Note

Hi, this is (your name). I am caring for Ms.

Sonia Best in room 307, a 56-year-old female, who is post op day 2 for left BKA due to non-healing diabetic foot ulcer.

Prompt:

What background information do I need to know?

User Response

had leg amputation, The patient is diabetic

Model Note

Ms. Best was admitted two days ago for surgical removal of her left lower leg below the knee. She has a history of diabetes mellitus Type II, peripheral vascular disease, and coronary artery disease. At home, she takes both long-acting insulin glargine and dapagliflozinan, an oral antidiabetic. She is also taking aspirin and rosuvastatin.

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