Language that signals deterioration

Patients and callers often describe worsening illness in everyday words. Terms such as "worse", "confused", "sleepy", "clammy", "not drinking", "not passing urine" or "not themselves" can be more important than the stated reason for the call.

These phrases should interrupt routine workflow when they indicate a clear change, rapid deterioration, or that the person may be unsafe waiting for a routine appointment.

Listen or look for

• New confusion, drowsiness, slurred speech or not making sense.
• Breathlessness: unable to finish sentences, blue lips, gasping, noisy breathing or becoming short of breath while speaking.
• Sudden or worsening weakness: too weak to stand, falling, unable to get out of bed or unable to manage at home.
• Reduced intake or output: unable to drink, repeated vomiting, no urine, very little urine or signs of dehydration.
• Severe pain, rigors, mottled skin, clamminess or a strong sense that something is seriously wrong.
• Repeated contact: the patient or carer calls again because symptoms have worsened or previous advice has not helped.

Preserve the change over time

Deterioration is often established by comparison. "Normally walks to the shops, now cannot stand" is more informative than "weak". "Phoned this morning and now sounds breathless" is more informative than "called again".

Do not soften urgent wording into vague notes such as "unwell", "wants advice" or "not coping". The next clinician needs to see the same level of concern that the caller expressed.

Repeat contact note

When the story is about worsening, record the change as clearly as the symptom.