BEHAVIOUR RESPONSE SCORE

Spontaneously 4
Eye opening
To speech 3
To pain 2
No response 1
Oriented to time, place and person 5
Best verbal Confused 4
response Inappropriate

words 3
Incomprehensible sounds 2
No response 1
Best motor Obeys commands 6

response Move to localised pain 5

Flexion withdrawal from pain 4
Abnormal flexion (decorticate) 3
Abnormal extention (decerebrate) 2
No response 1
@RNursingNotes
 S
n oit auti S
Identify yourself and where you are calling from
Identify the patient by name and reason for call
Describe your concern

Give the patient's reason for admission, admitting diagnosis and date of
dnuorgkcaB tnemssessA noitadnemmoceR

admission
Background to current problem
Relevant medical history/ co-morbidity
Relevant treatment so far
B
What is your assessment?

A
What have you done so far?
OR: ''Unsure of the probelm but I'm worried''
NEWS/ vital signs / ABCDE / Clinical impression

Be specific about request: Do you want telephone advice? Patient assessment?

Be specific abou time frame ''this patient requires review within_minutes''
Make suggestions

R
Clarify expectations
Record name and contact number of the contact
''Is there anything I need to do in the meantime?''